"RFf^G 


Columbia  (MnttJer^iftp 

College  of  ^fipsicianss  anb  ^urgeong 
Hibrarp 


>tate  Universfty  of  !ow^, 
Medical  Library 


Digitized  by  the  Internet  Arciiive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/practicalobservaOOwild 


THE  NATURE  AND  TREATMENT 


DISEASES   OF   THE   EAR. 


PRACTICAL  OBSERVATIONS 


AUEAL     SUEGERY 


THE  NATURE  AND  TREATMENT 


DISEASES   OF   THE   EAR 


50itli  SlUstrntintiH. 


WILLIAM   R.    WILDE, 

FELLOW   OF  THE  EOYAL  COLLEGE   OF   STTRGEOXS  IN  IRELAND;   SURGEON  TO  ST.  MARK'S   OPHTHALMIC 
hospital;   honorary  member   of  the  royal  medical  society   OF   STOCKHOLM,    ETC.,   ETC. 


PHILADELPHIA: 

BLAN  CHARD     &     LEA. 
1853. 


C.    SHERMAN,    PRINTER, 

19  St.  James  Street. 


TO 


HIS    EXCELLENCY, 


EDWARD  GRANVILLE,  EARL  OF  ST.  GERMANS, 

LORD  LIEUTENANT  QENEEAL  AND  GENERAL  GOTERNOE  OF  IRELAND,  ETC., 


'^jlis  Wuk 


BY   HIS   excellency's  PERMISSION, 

DEDICATED, 

AS    A    MARK   OF   RESPECT   FOR   HIS   PUBLIC  CHARACTER, 

AND   OF   PERSONAL   GRATITUDE, 

BY 

THE  AUTHOR. 


PREFACE 

TO   THE   AMERICAN   EDITION. 


In  offering  an  American  edition  of  Mr.  Wilde's  work  on  Aural 
Surgery  to  the  profession,  it  is  confidently  hoped  that  it  will  fill  a 
void  in  our  Medical  literature  which  has  long  been  felt,  and  which 
no  work  published  in  this  country  has  ever  been  adequate  to  fill. 
No  work  has  yet  appeared  in  the  English  language,  which  has 
entered  so  extensively  into  the  pathology  and  treatment  of  the 
Diseases  of  the  Organ  of  Hearing,  as  that  now  offered  to  the  pro- 
fession; and  it  is  to  be  earnestly  hoped  that  the  objects  of  the  author 
— "to  lay  down  just  principles  for  an  accurate  diagnosis  of  Diseases 
of  the  Ear ;  to  rescue  their  treatment  from  empiricism,  and  found  it 
upon  the  well-established  laws  of  modern  pathology,  practical  sur- 
gery, and  reasonable  therapeutics" — may  be  alike  accomplished  in 
the  new  world  as  in  the  old. 

The  work  is  a  practical  one,  the  result  of  extensive  experience,  and 
could  have  been  undertaken  by  few  men  as  well  fitted  for  it  as  the 
author.  Possessed  of  extraordinarily  quick  perceptive  faculties, 
highly  cultivated  by  early  discipline  and  use,  of  mature  judgment 
und  consummate  skill,  of  untiring  zeal  and  industry,  and  of  high 
literary  attainments,  few  surgeons  have  had  better  opportunities,  or 
could  have  made  better  use  of  them,  than  Mr.  Wilde.  St.  Mark's 
Hospital  for  Diseases  of  the  Eye  and  Ear,  the  field  of  his  public 
labors  in  these  branches,  is  an  institution  of  his  own  creating,  which 
has  been  in  operation  nearly  ten  years,  and  is  now  one  of  the  largest 
and  best  conducted  of  the  kind  in  Great  Britain.     All  those  who 


XU     ■  PREFACE    TO    THE    AMERICAN    EDITION. 

have  had  the  good  fortune  of  attending  his  clinics,  and  observing  his 
practice  there,  will,  like  ourselves,  -willingly  bear  testimony  to  their 
admiration  of  his  talents. 

The  American  edition  has  been  prepared  from  the  early  proof 
sheets  of  the  original,  and  appears  as  nearly  contemporaneous  with 
it  as  the  circumstances  of  distance  and  consequent  unavoidable  delay 
would  allow.  The  additions  which  have  been  made  to  it  are  but  few 
in  number,  and  have  been  introduced  either  as  containing  matters  of 
interest  in  connexion  with  the  subject,  or  to  illustrate  the  original 
text,  and  are  in  all  instances  included  within  brackets,  and  marked 
with  the  initials  of  the  editor,  and  the  sources  given  from  whence 
they  were  obtained. 

Addinell  Hewson. 

Philadelphia,  105  South  Tenth  Street. 
August,  1853. 


Al'THOE-'S    PREIACT. 


Lv: 

■.-i 

I-::-: 

;;: 

:r~ 

f;: 

^-  T-^r, 

cuii;:; 

.:.; 

;ri  ;,:: 

V- 

--'  " 

fa:;rT 

~-""^i.' 

"  i 

—  > ; 

rer  I  hare  entered  so  fallT  into  the  cir- 
^^'■'Stion  of  this  ^ork.  that  but  few  pre- 
V.  I  have  labored,  and  I  trust  not 
in  Tain,  to  exp<^e  error  and  establish  truth ;  to  lay  down  just  prin- 
taples  for  an  accurate  diagnosis  of  Diseases  of  the  Ear ;  to  rescue 
-■  :"     Treatment  from  ^npiricism,  and  found  it  upon  the  well-esta- 

;  1?^5  of  mo'iem  pathology,  practical  surgery,  and  reasonable 
:  T 1;^  ::  :5.  In  iriliLg  with  my  subject  it  was  necessary  to  review 
the  practice  and  opinions  of  others :  yet,  though  on  certain  points  a 
conscientious  difference  from  other  writers  has  been  expressed,  I  have 
not  failed  to  award  merit  where  merit  was  due. 

M-r  frvrid  and  former  pupil.  Dr.  Addinell  Hewson,  of  Philadel- 
pL:  .  .  -  insented  to  edit  the  American  edition  of  this  book,  now  in 
course  of  publication  by  Messrs.  Blanchard  and  Lea ;  and  my  friend 
Dr.  von  Haselberg,  of  Stralsund,  has  kindly  undertaken  the  transla- 
tion of  it  int:   'jrrrziiill. 

BiTBua,  21  WssnuLSB  Row, 
Jime  12,  1S53. 


CONTENTS. 


CHAPTER  I. 

FA6B 

Introduction  axd  Bibliography, 17 

CHAPTER  11. 
Means  of  Diagnosis, 62 

CHAPTER  III. 
Statistics  and  Nosology  op  Ear  Diseases, 104 

CHAPTER  IV. 
Diseases  of  the  Auricle,  Mastoid  Region,  and  External  Meatus,  .     .     154 

CHAPTER  V. 
Diseases  of  the  Membrana  Tympani, 209 

CHAPTER  VI.  . 
Diseases  of  the  Middle  Ear  and  Eustachian  Tube, 299 

CHAPTER  VII. 
Diseases  of  the  Internal  Ear, 353 

CHAPTER  VIIL 
Otorrhoea, 374 

APPENDIX. 

Deaf-Dumbness, 412 

Index, 467 


^ 


A  TREATISE 


DISEASES  OF  THE  EAR. 


CHAPTER    I. 

INTRODUCTION   AND    BIBLIOGRAPHY. 

Introductory  Remarks  on  Aural  Surgery. — Former  means  of  Diagnosis,  and  general 
knowledge  of  the  subject. — Early  History  of  the  Art. — Writings  of  the  Ancients  from 
Hippocrates  to  Galen. — Discoveries  of  the  Anatomists  of  the  fifteenth  century. — Irish 
Translations. — Mercurialis. — Instruction  of  the  Deaf  and  Dumb. — Heurnius. — Introduc- 
tion of  the  Speculum  by  Fabricius. — Bonet  and  Du  Verney. — Kennedy. — Eustachian 
Catheterism  by  Guyot. — English  Aurists  :  Cleland  and  Wathan. — Leschevin. — Degra- 
vers. — Valsalva-  and  Cassebohm. — Sims  and  the  London  Medical  Society. — Graham 
and  Elliott. — Quacks  and  Quackery. — Perforation  of  Mastoid  Process. — Cheselden. — 
Perforation  of  the  Membrana  'I'ympani  by  Sir  A.  Cooper. — Saunders. — Curtis  and  his 
followers;  Stephenson,  Williams,  Wright,  Webster,  Hepworth,  and  Gardner. —  Bu- 
chanan, Earle,  Tod,  Swan,  and  Caswell. — The  French  School:  Laennec,  Itard,  and  De- 
leau. — The  German  School:  Kramer,  Schmalz,  Lincke,  and  Frank. — The  Modern  En- 
glish School :  Toynbee,  Pilcher,  Wharton  Jones,  Williams,  Yearsley,  Harvey,  Dufton, 
and  Wakeley. — Turnbull  and  his  Reviewers. — Requisites  for  an  Aural  Surgeon,  and 
what  Aural  Surgery  can  effect. 

In  the  following  Treatise  I  purpose  Avriting,  for  the  information  of 
practitioners  and  students  in  medicine,  the  history,  symptoms,  causes, 
mode  of  treatment,  and  results  of  the  most  frequent  and  remarkable 
diseases  of  the  Ear.  With  respect  to  my  competency  to  this  task,  I 
have  but  to  remark,  that  I  have  had  very  ample  opportunities  for 
studying  these  diseases  during  the  last  ten  years  in  an  extensive  prac- 
tice, and  in  the  management  of  a  large  public  institution  in  Dublin, 
for  a  long  time  the  only  one  of  the  kind  open  to  the  student  where 
clinical  and  practical  instruction  in  Aural  Surgery  was  delivered  in 
Great  Britain. 

This  work  is  the  result  of  the  experience  thus  acquired.     Detached 

2 


18  INTRODUCTORY    REMARKS. 

portions  of  it,  clinical  lectures,  and  cases  observed  at  St.  Mark's 
Hospital,  have  already  appeared  in  the  periodicals  of  this  country, 
and  some  of  these  essays  have  been  translated  and  published  sepa- 
rately on  the  Continent.  All  these,  together  with  much  additional 
information  gleaned  since  their  publication,  are  embodied  in  this 
book,  which  does  not  profess  to  be  a  complete  system  of  Aural  Sur- 
gery, giving  a  full  description  of  all  the  diseases  of  the  Ear  which 
have  been  recorded  by  authors ;  but  is  intended  to  supply  the  reader 
with  a  practical  treatise  on  the  most  frequent  and  urgent  affections 
of  the  organ  of  hearing,  and  those  that  I  myself  am  best  acquainted 
with.  It  may,  therefore,  be  regarded  somewhat  in  the  light  of  a 
monograph,  a  form  of  publication  peculiar  to  this  School,  and  one 
generally  containing  more  useful  and  practical  information  than 
either  a  large  systematic  work  or  a  manual. 

In  studying  the  diseases  of  the  Ear,  my  object  has  been  to  take 
as  a  basis  the  principles  of  pathology  :  and  to  reduce  their  treatment, 
local  as  well  as  general,  to  the  recognised  rules  of  modern  therapeu- 
tics and  scientific  surgery ;  but,  above  all,  I  have  labored  to  divest 
this  branch  of  medicine  of  that  shroud  of  quackery,  medical  as  well 
as  popular,  with  which,  until  lately,  it  has  been  encompassed. 

Country  friends  often  ask  me,  "  Have  you  found  out  any  new  cure 
for  deafness  ?"  I  do  not  profess  to  invent  or  introduce  new  reme- 
dies. I  try  to  make  the  well-established  rules  of  practice  in  the 
treatment  of  other  organs  applicable  to  the  management  of  aural 
diseases.  Like  most  students,  I  was  taught  during  my  apprentice- 
ship theoretically  to  believe,  and  practically  to  observe,  that  we 
"knew  nothing  about  the  diseases  of  the  organs  of  hearing."  This 
was  the  dictum  honestly  expressed  by  the  "  heads  of  the  Profession," 
— men  from  whom  the  public  were  willing  to  receive  a  fearless,  can- 
did opinion,  either  immediately  on  being  consulted,  or  after  a  few 
trials  of  the  "  ordinary  means ;"  to  wit,  syringing  with  hot  water  and 
soap,  either  Castile,  soft,  yellow,  or  old  brown  Windsor,  in  the  hope 
that  the  deafness  or  the  noise  in  the  ears  might  arise  from  a  collec- 
tion of  hardened  wax ; — then  setting  the  digestive  organs  to  rights 
by  purgation,  and  a  "  course  of  bitters,"  lest  the  affection  might  he 
"owing  to  the  stomach."  The  human  stomach  has  much  to  answer 
for  in  deranging  the  system  generally,  no  doubt ;  but  the  mischief  of 
which  it  is  daily  accused,  as  every  one  extensively  engaged  in  practice 
is  well  aware,  is  beyond  belief.  There  is  scarcely  a  disease  which 
we  treat,  no  matter  how  local,  upon  which,  if  we  question  the  patient 


FOEMER    MEANS     OF    DIAGNOSIS    AND    TREATMENT.       19 

as  to  its  duration,  that  lie  will  not  say,  "  Oh !  it  is,  indeed,  of  pretty 
long  standing,  but  I  was  waiting  to  have  my  stomach  put  to  rights, 
as  I  am  told  I  am  very  bilious."  Next  in  order,  blistering  behind 
the  ears  is  tried,  in  order  to  draw  away  some  peccant  humor  that 
had,  perhaps,  accumulated  round  the  delicate  organ  of  hearing. 
These  and  such  like  methods  failing  to  give  relief,  stimulants,  often 
of  a  very  acrid  nature,  are  poured  into  the  external  auditory  pas- 
sages, either  to  restore  the  secretion, — under  the  impression  that 
what  is  a  mere  attending  symptom  is  the  disease, — or  to  excite  or 
rouse  the  dormant  nervous  power;  and  hot  tinctures,  turpentine, 
creasote,  and  pungent  essential  oils,  are  applied  to  the  external  sur- 
face of  the  tympanal  membrane  without  mercy.  Some  practitioners 
resort  to  more  palliative  means,  recommending  some  warm  almond 
oil  to  be  dropped  into  the  ear  at  bedtime,  or  eau  de  Cologne  to  be 
rubbed  upon  the  side  of  the  cheek  adjoining  the  auricle,  at  the  same 
time  advising  a  little  black  wool  to  be  retained  in  the  meatus,  in  order 
to  preserve  the  organ  from  cold.  To  give,  however,  fair  play  to  the 
latter  remedy,  it  should  be  prescribed  in  full,  and  according  to  the 
old  popular  superstition,  but  one  which  is  still  extensively  resorted 
to, — the  wool  should  be  procured  from  the  left  fore-foot  of  a  six 
years'  old  black  ram  !  Some  advise  a  slice  of  fat  bacon  to  be  inserted 
into  the  meatus  every  second  night ;  and  glycerine  is  now  the  fash- 
ionable remedy.  All  these  means  having  failed  to  give  relief,  the 
patient  is  frequently  recommended — an  easy  mode  of  getting  rid  of 
him — to  give  galvanism  and  electricity  a  fair  trial ;  and  if  they  do 
not  succeed,  change  of  air  and  scene,  sea-bathing,  or  a  "  course  of 
waters"  at  some  of  the  fashionable  places  of  resort  for  that  purpose 
is  prescribed.  Despairing  of  relief  from  the  legalized  practitioner, 
and  getting  disheartening  opinions  from  men  of  eminence  and  repute, 
we  need  not  wonder  that  suffering  patients  throw  themselves  into  the 
hands  of  quacks  and  nostrum-mongers. 

Moreover,  the  difficulties  which  beset  the  student  in  acquiring  a 
knowledge  of  the  anatomy  of  the  ear,  owing  to  the  exceeding  minute- 
ness of  the  organ  itself,  the  great  difficulty  of  dissecting  it,  from  its 
depth,  the  complexity  of  its  structure,  and  the  small,  hard  bone  in 
which  it  is  placed,  as  well  as  the  number  of  crabbed  names  attached 
to  its  different  parts,  all  of  which  have  made  it  a  sort  of  anatomical 
crux,  which  no  one  wishes  to  remember  longer  than  the  day  after  he 
has  passed  his  examination,  have  conduced  not  a  little  to  strengthen 
the  belief  in  the  doctrine  promulgated  by  his  instructors,  that  little 


20        CAUSES    OF    OPPROBRIUM    IN    AURAL    SURGERY. 

or  nothing  could  be  done  to  reach  the  diseases  of  so  delicate  and  in- 
tricate an  organ. 

Now,  notwithstanding  the  remarks  which  we  hear  daily  in  society, 
or  which  we  meet  with  in  the  periodic  and  "manual"  literature  of 
the  day, — that  the  treatment  of  diseases  of  the  ear  is  an  opprobrium 
to  medicine, — the  progress  which  this  branch  of  medical  science  is 
making  is  in  all  probability  as  rapid  as  that  in  any  other  department 
of  the  healing  art.  Among  the  many  causes  from  which  this  opinion 
has  arisen,  there  are  two  which  must  pre-eminently  attract  the  atten- 
tion of  any  person  conversant  with  the  subject,  or  who  will  calmly 
examine  into  the  question.  The  first  is,  that  heretofore  the  treatment 
of  those  diseases  has  been  committed  to  the  hands  of  the  most  unedu- 
cated quacks  and  charlatans,  male  and  female, — persons  totally  un- 
acquainted with  the  first  rudiments  of  medical  knowledge  ;  the  second, 
that  medical  men  themselves — most  astute  and  practical  physicians 
and  surgeons  in  all  other  respects — treat  diseases  of  the  ear  certainly 
in  a  manner  that  savors  of  empiricism,  by  prescribing  nostrums,  of 
both  a  local  and  general  character,  which  we  know  they  would  never 
think  of  using  in  similar  forms  of  disease  in  any  of  the  other  organs 
of  the  body.  Tliis  latter  cause  evidently  results  from  want  of  proper 
attention  to  the  subject  in  our  schools,  and  from  the  practice  of  pre- 
scribing at  random  for  diseases,  the  diagnosis  and  pathology  of  which 
are  generally  unknown. 

To  both  these  causes  may  be  added  others  that,  to  a  certain  degree, 
serve  to  bias  the  public  mind  against  the  treatment  of  aural  diseases. 
In  many  cases,  there  is  either  an  unconsciousness  of  the  insidious 
approaches  of  deafness,  or  an  unwillingness  to  admit  even  the  possi- 
bility of  such  an  occurrence ;  or,  again,  there  is  an  apathy,  to  a 
greater  or  less  degree,  on  the  part  of  those  aifected  with  deafness, 
and  a  delay  in  seeking  advice,  which  is  scarcely  credible.  Persons 
who,  if  they  suffer  the  least  inconvenience  in  any  of  their  functions, 
or  the  slightest  interference  with  the  due  exercise  or  healthy  condi- 
tion of  any  of  the  other  organs  of  sense,  would  immediately  apply 
for  medical  relief,  and  submit  to  any,  even  the  most  severe  form  of 
treatment,  will  patiently  permit  the  sense  of  hearing  to  be  greatly 
impaired,  nay,  even  lost  on  one  side,  without  making  any  effort  for 
its  restoration.  When  the  lapse  of  months,  and  even  years,  have 
contributed  to  confirm  disease  and  render  such  persons  incurable, 
they  generally  respond  to  inquiries  with  regard  to  previous  treatment, 


THE    EARLY    HISTORY     OF    AURAL     SURGERY.  21 

— that  they  did  not  like  to  be  "tampering"  with  their  ears,  or,  that 
they  were  told  nothing  could  be  done  for  them. 

It  would  in  no  wise  conduce  to  the  practical  eifect  to  which  I  hope 
this  work  may  tend,  to  inquire  into  all  the  causes  of  these  results :  I 
may,  however,  mention,  that  medical  men  themselves  have  in  part 
conduced  to  produce  this  want  of  faith  on  the  part  of  the  public, 
either  by  direct  opinion  as  to  the  incurable  nature  of  the  disease  or 
diseases  known  by  the  symptom  of  deafness,  or  by  such  futile  treat- 
ment as  broke  down  the  conj&dence  of  the  patient  in  any  remedy  for 
diseases  of  the  organs  of  hearing.  It  is  true  that  cases  of  what  are 
termed  "nervous  deafness,"  that  is,  of  defect  in  the  hearing  function 
of  the  acoustic  nerve  in  any  part  of  the  internal  ear,  from  paralysis 
or  other  causes, — or  of  those  portions  of  the  brain  which  preside 
over  the  faculty  of  hearing,  or  give  origin  to,  or  are  connected  with 
the  portio  mollis  of  the  seventh  pair  of  nerves, — in  fact,  such  cases 
as  are  analogous  to  amaurosis, — are  as  intractable  as  that  disease  of 
the  eye  ; — yet  I  fear  not  to  reiterate  the  assertion  which  I  made  upon 
several  former  occasions,  that  if  the  diseases  of  the  ear  were  as  well 
studied  or  understood  by  the  generality  of  practitioners,  and  as  early 
attended  to,  as  the  diseases  of  the  eye,  it  would  be  found  that  they 
were  just  as  much  within  the  pale  of  scientific  treatment. 

We  have  now  several  special  works  upon  aural  surgery,  as  well  as 
some  valuable  monographs  thereon  in  the  cyclopaedias  and  periodicals, 
yet  it  is  to  be  regretted  that  the  modern  systems  of  surgery  contain 
but  scanty  information  upon  the  subject  of  diseases  of  the  ear.  The 
following  passage  from  M.  Druitt's  well-arranged  "  Surgeons'  Vade 
Mecum"  (which  is  an  exception  to  the  class)  is  so  apposite  to  the  fore- 
going observations,  that  I  insert  it : — "  Deafness  is  so  common  and 
so  distressing  an  infirmity,  and,  when  of  long  standing,  is  so  incurable, 
that  we  cannot  too  strongly  urge  all  medical  practitioners  to  make 
themselves  familiar  with  the  treatment  of  diseases  of  the  ear.  They 
should  also  encourage  their  patients  to  apply  to  them  for  the  relief 
of  slight  and  incipient  ailments  in  this  organ,  instead  of  allowing 
them  to  go  on  till  they  become  permanently  deaf,  and  then  letting 
them  fruitlessly  seek  relief  from  ignorant  and  mercenary  quacks." 

THE    EARLY    HISTORY    OF    AURAL    SURGERY. 

In  the  present  day,  when  literature  in  every  Protean  shape  and 
form  has  compassed  the  land,  and  knowledge  may  truly  be  said  to 


22  THE    EARLY    HISTORY    OF    AURAL    SURGERY, 

run  to  and  fro  throughout  the  earth ;  and  when  the  polyglot  cyclo- 
paedia of  the  Press  has  outstripped  in  the  race  all  other  feats  of 
human  prowess  of  the  nineteenth  century,  it  might  be  deemed  unne- 
cessary to  follow  the  old  school  system  of  detailing  the  early  history 
of  that  particular  branch  of  medicine  of  which  this  essay  treats,  were 
it  not  that  in  an  art  but  just  emerging  from  the  darkness,  ignorance, 
empiricism,  prejudice,  and  superstition,  which  is  to  a  certain  extent 
even  yet  the  condition  of  aural  surgery,  its  history  not  only  becomes 
interesting,  but  practically  instructive.  Furthermore,  as  this  work  is 
not  put  forward  as  a  system  containing  a  compilation  of  opinions,  or 
abounding  in  extracts  and  references,  but  is  chiefly  the  result  of  my 
own  experience,  the  following  notices  of  the  writings  of  others  is 
given  with  a  view  of  directing  the  student  to  the  most  accessible 
sources  of  information  on  the  subject. 

I  might,  with  the  generality  of  writers  upon  the  history  of  medi- 
cine, commence  with  the  times  of  Hippocrates,  for  he  makes  several 
allusions  to  the  afiections  of  the  organs  of  hearing,  not,  however,  as 
idiopathic  forms  of  disease,  but  as  symptomatic  of  other  maladies  of 
an  acute  or  chronic  nature ;  but  it  must  be  borne  in  mind  that  at 
that  period  of  medical  science  (and,  I  regret  to  add,  that  it  has  in  a 
great  part  descended  to  the  present  day)  the  affections  of  the  ear, 
whether  functional  or  organic,  were  spoken  of,  lectured  on,  written 
of,  and  described,  not  according  to  the  laws  of  pathology  which  regu- 
late other  diseases,  but  by  a  single  symptom,  that  of  deafness. 
"If,"  says  Dr.  Kramer,  "I  mention  that  the  treatment  of  deafness 
(viz.  as  it  occurs  as  a  functional  disorder  only  of  the  ear,  without 
any  perceptible  external  alteration  of  the  organ)  merely  consists  of 
not  washing  out  the  ear,  but  cleansing  it  with  wool,  dropping  in  oil, 
directing  the  patient  to  walk  out,  rise  early,  drink  white  wine,  ab- 
stain from  salads,  and  allowing  him  to  eat  bread,  and  such  fish  as  in- 
habit rocky  shores,  I  shall  have  collected  all  that  is  of  most  import- 
ance to  give  an  idea  of  acoustic  medicine  at  that  time." 

To  Celsus,  the  successor  of  Hippocrates,  we  are  indebted  for  the 
first  acknowledgment  of  the  specific  or  independent  forms  of  aural 
disease ;  for  having  introduced  the  practice  of  ocular  inspection  of 
the  auditory  canal ;  and  for  some  general  rules  for  the  treatment  of 
the  inflammatory  affections  of  the  organs  of  hearing.  But  this 
advance  in  aural  medicine,  which  we  owe  to  Celsus,  is  more  than 
counterbalanced  by  his  introduction  into  practice  of  those  stimulating 
nostrums  which  were  then,  and  have  been  since,  applied  to  the  mem- 


FROM  THE  TIMES  OF  HIPPOCRATES  TO  CELSUS.   23 

brana  tympani  without  discrimination ;  and  many  of  which  are  made 
use  of  in  the  present  day. 

Galen  followed  in  the  track  of  his  great  predecessor,  and  although 
he  advanced  somewhat  in  symptomatology,  and  was  evidently  better 
acquainted  with  the  causes  of  the  inflammatory  diseases  of  the  ear, 
yet  he  and  his  disciples  so  increased  the  number  of  remedial  agents 
which  were  applied  to  the  external  meatus,  that  we  find  aural  medi- 
cine and  surgery,  toward  the  end  of  the  fifteenth  century,  but  a 
collection  of  hard  names,  unconnected  symptoms,  fanciful  and  absurd 
theories  based  on  causes  the  most  improbable,  and  a  category  of 
medicinal  substances  from  the  animal,  mineral,  and  vegetable  king- 
doms, principally,  however,  composed  of  hot  spices  and  stimulating 
applications,  of  which  I  may  mention  castor,  ox-gall,  garlic,  frank- 
incense, opium,  nitre,  euphorbium,  alum,  iron  filings  boiled  on  vinegar, 
hellebore,  myrrh,  and  many  other  such  substances,  each  lauded  by 
their  respective  admirers,  and  extolled  as  panaceas  for  deafness  in  all 
its  numerous  forms  and  modifications ;  as  we  find  glycerine  is  at  the 
present  day.  Those  who  still  prescribe  such  nostrums,  and  they  are 
many,  might  consult  with  advantage  old  "  Gabelhover's  Boocke  of 
Physicke,"  printed  in  1559. 

It  would  afi"ord  us  neither  literary  interest  nor  practical  utility, 
commensurate  with  the  task,  to  detail  the  notions  concerning  the 
treatment  and  diseases  of  the  ear,  as  they  may  be  found  scattered 
throughout  the  writings  of  Aurelianus,  Paul  of  ^gina.  Razes,  Sera- 
pion,  Hali  Abbas,  Mesne,  and  Dioscorides  ;  the  works  of  the  three 
latter  of  whom  were  translated  into  Gaelic  by  several  distinguished 
Irish  physicians  from  the  beginning  of  the  fourteenth  to  the  end  of 
the  sixteenth  century.'^ 

At  the  conclusion  of  the  fifteenth  century  the  anatomy  of  the  ear 
received  a  new  impulse,  by  the  investigations  and  discoveries  of  some 
of  the  most  distinguished  anatomists  and  physicians  of  that  age,  in 
compliment  to  whose  labors  subsequent  writers  gave  those  parts 
names  which  we  retain  to  the  present  day,  as,  the  tube  of  Eustachius, 
the  aqueduct  of  Fallopius,  the  liquor  of  Cotunno,  and  the  fissure  of 
Casserius ;  but  although  these  celebrated  men  made  the  world  better 
acquainted  with  the  anatomy  of  the  organ  of  hearing,  and  thus  re- 

'  See  the  author's  Introduction  to  the  memoir  on  Vital  Statistics  in  the  Census  of  Ire- 
land for  1841  ;  and  also  a  Lecture  on  the  Early  History  of  Irish  Medicine,  delivered 
at  the  College  of  Physicians,  and  published  in  the  Medical  Gazette  for  18th  February, 
1848,  et  seq. 


24       FIRST    INSTRUCTION    OF    THE    DEAF    AND    DUMB. 

moved  one  of  the  chief  obstacles  to  the  investigation  of  aural  pa- 
thology, their  successors  in  medicine  advanced  but  little  in  the  diag- 
nosis and  treatment  of  diseases  of  the  ear. 

The  first  special  work  upon  the  ear  that  I  have  been  able  to  dis- 
cover is  that  of  Heurnius  Mercurialis,  "  De  oculorum  et  aurium 
affectihus  Prcelectiones,''  the  first  edition  of  which  was  published  at 
Frankfort  in  1584.  Mercurialis  was  chiefly  a  compilator  from  the 
works  of  the  Greeks,  Romans,  and  Arabians,  and  as  an  original  in- 
investigator  deserves  no  credit ;  but  he  collected  all  that  was  known 
and  had  been  written  before  his  day  on  aural  diseases ;  the  little  he 
did  add  was  that  of  a  few  more  nostrums,  and,  therefore,  he  may  be 
consulted  with  advantage  by  those  of  the  fraternity  who  still  adhere 
to  the  good  old  rule  of  applying  such  remedies  as  hot  onions  in  acute 
inflammations  of  the  meatus  or  tympanum. 

In  the  sixteenth  century  the  attention  of  philanthropists  was  first 
turned  toward  the  lamentable  condition  of  the  deaf  and  dumb. 
Prior  to  that  period,  during  those  ages  wont  to  be  called  enlightened, 
and  in  th^ose  countries  styled  civilized  and  even  refined — among  the 
Egyptians,  Greeks,  Romans,  and  Hebrews,  the  deaf  mute  was,  and 
even  still  in  the  Orient  is,  but  little  removed  from  the  brute,  and  is 
often  employed  for  the  basest  and  most  degrading  ofiices,  such  as 
humanity  in  the  present  day,  in  this  country  at  least,  shudders  at. 
Up  to  that  period  the  deaf  and  dumb  were  not  considered  susceptible 
of  improvement  or  instruction  of  any  kind,  and  their  very  passions, 
unrestrained  by  any  influence,  human  or  divine,  were  frequently  made 
to  minister  to  the  cruelty  or  sensuality  of  those  around  them.  I 
need  not  further  enlarge  upon  this  subject  here,  as  it  is  considered  at 
length  in  the  section  of  this  work  devoted  to  deaf-dumbness. 

The  first  book  that  treated  of  our  subject  in  the  seventeenth  cen- 
tury was  a  posthumous  Latin  Avork  of  Joseph  Heurnius,  on  the 
diseases  of  the  organs  of  hearing,  published  by  his  son,  the  cele- 
brated Otho  Heurnius,  in  1602.  Lincke,  however,  says  that  he  was 
but  a  compiler.  Heretofore  the  treatment  of  aural  diseases  consisted, 
as  already  remarked,  for  the  most  part,  in  medicinal  agents  and 
empirical  nostrums ;  but  in  1646  the  principles  of  surgery  were 
brought  to  bear  upon  this  class  of  affections  by  the  master-mind  of 
Fabricius  von  Hilden.  His  observations  on  the  extraction  of  foreign 
bodies,  on  polypi,  and  other  diseases  of  the  external  auditory  conduit, 
are  well  worthy  of  perusal ;  and  to  him  is  generally  ascribed  the  in- 
vention of  the  first  speculum  auris,  as  well  as  the  first  ear  instruments 


LABORS     OF    PABRICIUS    AND     DU    VERNEY.  25 

on  record.  His  speculum  was  formed  on  the  principle  of  the  common 
forceps-like  instrument  still  in  use  ;  but  from  the  following  passage 
in  a  still  older  writer,  Peter  de  la  Cerlata,  "^er  inspectionem  ad  so- 
lem  traliendo  aurem  et  ampUando  cum  speculo  aut  alio  instrumento," 
we  are  led  to  believe  that  means  were  employed  before  his  time  for 
examining  the  external  auditory  passage.  Instruments  of  this  kind, 
and  for  this  pui'pose,  having  been  once  recognised  and  employed  by 
practitioners,  have  since  been  variously  modified,  according  to  the  in- 
genuity of  the  inventor ; — yet  their  fii'st  introduction  into  practice 
decidedly  formed  an  epoch  in  aural  surgery.  Fabricius's  observa- 
tions, and  the  description  of  his  instruments,  will  be  found  in  his 
"  Opera  Omnia." 

The  next  work  of  any  merit  that  appeared  in  connexion  with  aural 
medicine  was  published  by  a  Genevese  anatomist,  Theophilus  Bonet ; 
his  observations,  as  they  are  set  forth  in  his  great  work,  the  "  Sepul- 
cretum  vel  Chirurgica  Practica,"  were  chiefly  confined  to  the  pa- 
thology of  the  ear  from  dissection ;  but  in  a  practical  point  of  view 
he  advanced  little  beyond  the  limits  attained  by  his  predecessors. 

Towards  the  conclusion  of  the  seventeenth  century  am^al  surgery 
received  a  new  impulse  from  the  talents  and  laborious  investigations 
of  the  distinguished  French  anatomist,  Du  Verney.  Of  late  it  has 
become  the  fashion  to  decry  the  labors  of  this  great  man — in  my 
humble  judgment,  unjustly — for  he  was  far  in  advance  of  his  time, 
and  although  the  pathological  is  not  as  voluminous,  nor  perhaps  as 
accurate  as  the  anatomical  part  of  his  writings  on  the  organ  of  hear- 
ing, still  he  was  a  lucid  painter,  and  a  graphic  describer  of  disease. 
He  was  the  first  person  who  arranged  the  diseases  of  the  ear  accord- 
ing to  the  anatomical  structures  afi"ected,  as,  into  those  of  the  outer 
ear  and  meatus,  those  of  the  middle  ear  or  tympanum,  and  those  of 
the  internal  ear  or  labyrinth.  From  the  times  of  Eustachius  to  the 
period  on  which  we  are  now  engaged,  we  have  no  work  upon  the 
anatomy  of  the  organ  of  hearing  equal  to  that  of  Du  Verney,  and 
to  this  day  it  may  be  consulted  with  advantage.  We  likewise  are 
indebted  to  Du  Verney  far  more  than  is  generally  acknowledged,  or, 
perhaps,  writers  are  aware  of,  for  having  given  the  first  impulse  to 
anything  like  a  knowledge  of  aural  anatomy  and  surgery  in  England  ; 
for  his  book,  which  was  published  in  Paris  in  1683,  was  translated 
into  English  after  his  death,  and  published  in  London  in  1737,  being 
thus,  though  a  translation,  the  first  special  treatise  in  point  of  time 
upon  aural  medicine  or  surgery  in  our  language.     This  is  now  very 


26  EUSTACHIAN    CATHETEKISM    BY    GUYOT. 

scarce,  yet  there  can,  I  think,  be  little  doubt  but  that  Mr.  Saunders 
availed  himself  largely  of  it.  However,  to  Du  Verney,  and  not  to 
Lallemand  and  Itard,  we  are  indebted  for  the  prejudice  that  up  to 
this  day  exists  with  regard  to  the  treatment  of  otorrhoea.  But  the 
latter  were  the  more  reprehensible,  as  from  the  age  in  which  they 
lived,  and  the  giant  growth  of  medical  knowledge  subsequent  to  the 
time  of  the  former,  they  should  have  known  better ;  but  I  believe, 
like  many  modern  practitioners,  they  chose  rather  to  transmit  the 
prejudices  of  one  hundred  and  fifty  years  before,  than  take  the 
trouble  of  investigating  for  themselves. 

Without  entering  minutely  into  the  history  of  aural  medicine  during 
the  latter  part  of  the  seventeenth  century,  which,  after  all,  would 
consist  in  the  enumeration  of  the  Latin  writings  of  various  Conti- 
nental authors,  more  curious  than  instructive,  let  us  pass  on  to  the 
penultimate  century  of  our  own  period,  when  aural  medicine  first 
dawned  in  .Great  Britain. 

In  1713,  Peter  Kennedy  published  in  London  a  little  work  styled 
"  Ophthajmographia,  or,  a  Treatise  on  the  Eye,"  to  which  is  added 
an  Appendix  of  some  of  the  diseases  of  the  ear,  wherein  is  observed 
the  communication  between  these  two  organs  ;  the  latter  part  consists 
of  about  ten  pages. 

It  is  remarkable,  that  the  discovery  which  Eustachius  made  of  the 
tube  which  bears  his  name  had  no  practical  influence  upon  this  branch 
of  medicine,  and  that  for  nearly  two  hundred  years  surgery  made  no 
effort  at  availing  itself  of  this  knowledge,  for  the  purpose  of  remedy- 
ing diseases  of  the  ear.  In  1724,  M.  Guyot,  a  postmaster  of  Ver- 
sailles, proposed  to  the  Parisian  Academy  of  Sciences  to  inject  the 
Eustachian  tube,  by  means  of  a  catheter  introduced  through  the 
mouth,  for  the  removal  of  obstructions  in  that  canal,  and  also  in  the 
middle  ear.  It  seems,  however,  that  the  French  academicians  were 
not  sufficiently  aware  of  his  valuable  discovery,  or  at  least  proposal, 
for  it  is  a  question  whether  he  ever  performed  the  operation  himself. 

In  1741,  Archibald  Cleland,  an  English  army  surgeon,  published 
in  the  Philosophical  Transactions  an  account  of  "  instruments  pro- 
posed to  remedy  some  kinds  of  deafness,  proceeding  from  obstructions 
in  the  external  and  internal  auditory  passages."  The  first  of  these 
consisted  "  of  a  convex  glass,  three  inches  in  diameter,  fixed  in  a 
handle,  into  which  is  lodged  some  wax  candle,  which  when  lighted 
will  dart  the  collected  rays  of  light  into  the  bottom  of  the  ear,  or  to 
the  bottom  of  any  cavity  that  can  be  brought  into  a  straight  line.'' 


ENGLISH    AURISTS CLELAZSTD WATHAN.  27 

Insignificant  and  incomplete  as  this  instrument  of  Cleland  undoubt- 
edly was,  it  is,  nevertheless,  deserving  of  our  attention,  inasmuch  as 
to  it  may  be  traced  the  subsequent  inspector  auris  of  Deleau,  of 
Itard,  Buchanan,  and  Kramer.  The  principal  object  of  Cleland's 
inspector  for  throwing  a  stream  of  artificial  light  into  the  meatus  was 
for  the  pui'pose  of  discovering  the  presence  of  hardened  cerumen, 
which  he  removed  by  means  of  a  jet  of  medicated  steam,  "  but  if," 
says  he,  "  this  has  not  the  desired  efiect,  and  the  person  still  remains 
deaf,  the  following  instruments  are  made  to  open  the  Eustachian 
tube ;  if  upon  trial  it  should  be  found  to  be  obstructed,  the  passage 
is  to  be  lubricated  by  throwing  a  little  warm  water  into  it,  by  a  syringe 
joined  to  a  flexible  silver  tube,  which  is  introduced  through  the  nose 
into  the  oval  opening  of  the  duct,  at  the  posterior  opening  of  the 
nares,  towards  the  arch  of  the  palate."  This  catheter  had  afiixed  to 
it  a  sheep's  ureter,  to  the  other  end  of  which  was  attached  the 
syringe,  "  whereby  warm  water  may  be  injected ;  or  they  will  admit 
to  blow  into  the  Eustachian  tube,  and  so  force  the  air  into  the  barrel 
of  the  ear,  and  dilate  the  tube  sufliciently  for  the  discharge  of  the 
excrementitious  matter  that  may  be  lodged  there."  He  likewise  used 
probes,  of  the  same  size  as  the  catheters,  to  explore  the  tube.  Cle- 
land was  either  unaware  of,  or  disbelieved,  the  account  of  Guyot's 
having  introduced  an  instrument  into  his  own  Eustachian  tube  through 
the  mouth,  nineteen  years  before ;  for  in  his  essay  in  the  Philosophi- 
cal Transactions  he  does  not  once  allude  to  the  circumstance.  To 
the  English  surgeon,  however,  is  undoubtedly  due  the  merit  of  having 
first  introduced  a  catheter  into  the  Eustachian  tube  through  the  nose, 
the  only  certain  way,  I  believe,  of  performing  such  an  operation. 

In  May,  1755,  Mr.  Jonathan  Wathan  published  a  more  detailed 
essay  in  the  Philosophical  Transactions,  on  "  a  method  proposed  to 
restore  the  hearing  when  injured  from  an  obstruction  of  the  tuba 
Eustachiana."  This  gentleman,  who  seems  to  have  been  a  good  prac- 
tical anatomist,  as  well  as  a  dexterous  surgeon,  had  an  opportunity 
of  making  a  post  mortem  examination  in  a  case  of  deafness,  wherein 
it  was  found  that  both  Eustachian  tubes  were  "  stuffed  quite  full  of 
congealed  mucus."  If  Cleland  overlooked,  or  was  unacquainted  with 
the  proposed  operation  of  the  Versailles  postmaster,  Wathan  seems 
to  have  completely  overlooked  the  more  recent  and  efiectual  discovery 
of  Cleland ;  but  in  allusion  to  the  post  mortem  examination  to  which 
I  have  just  referred,  he  says,  in  the  commencement  of  his  very  admi- 
rable essay :  "  As  all  these  concurring  circumstances  strengthen  me 


28  CLELAND  —  WATHAN. 

in  my  opinion,  they  likewise  incited  me  to  make  trial  of  an  operation 
that  "was  some  time  ago  proposed  to  the  Academy  of  Sciences  by  M. 
Guyot,  but  the  author  having  never  practised  it,  he  wanted  the  recom- 
mendation of  facts  to  support  and  enforce  it,  it  was,  therefore,  rejected 
by  them  as  impracticable."  And  in  a  note,  he  adds,  that  Guyot 
having  recommended  the  introduction  of  it  through  the  mouth,  which 
is  quite  impossible,  "  Petit  proposed,  and  that  learned  and  skilful  ana- 
tomist, Mr.  John  Douglas,  first  demonstrated  the  possibility  of  passing 
the  probe  through  the  nose  into  the  Eustachian  tube,  and  to  him  I 
freely  acknowledge  myself  indebted  for  the  hint."  The  catheter 
used  by  Mr.  Wathan  was  not  much  larger  than  a  common-sized  probe, 
and  was  bent  a  little  at  the  end,  very  nearly  in  the  same  form  as  that 
used  by  Kramer,  the  distinguished  Prussian  aurist ;  and  with  this 
and  a  syringe  he  injected  and  washed  out  the  Eustachian  tube  and 
middle  ear.  There  can  be  no  mistake  about  the  mode  of  Wathan's 
proceeding,  for  he  has  given  a  very  good  representation  of  the  ope- 
ration in  a  plate  attached  to  his  essay  in  the  Philosophical  Trans- 
actions.- 

I  have  dwelt  thus  long  upon  the  introduction  of  instruments  into 
the  Eustachian  tube,  as  that  operation  formed  the  second,  and,  per- 
haps, one  of  the  greatest  epochs  in  the  history  of  this  art,  because 
the  merit  is  due  to  our  own  countrymen,  and  because  the  English 
works  upon  aural  surgery  are  not  sufficiently  explicit  upon  this  point, 
and  many  of  the  Continental  ones  are  altogether  uninformed  with 
regard  to  it, — Dr.  Kramer,  in  his  critical  literary  review,  being  under 
the  impression  that  Guyot  had  really  introduced  the  catheter  through 
the  mouth. 

The  essays  of  Cleland  and  Wathan,  imperfect  as  they  were,  were 
decidedly  the  greatest  addition  to  aural  surgery  made  in  the  eigh- 
teenth century,  and  had  the  discoveries  and  valuable  observations  of 
these  practical  men  been  followed  up  in  England,  it  is  probable  we 
would  now  be  far  in  advance  of  our  Continental  neighbors.  I  would 
strongly  recommend  a  perusal  of  Wathan's  paper,  as  the  cases  he 
describes  are  most  valuable  in  the  diagnosis  of  obstruction  of  the 
Eustachian  tube. 

So  early  as  1842  I  was  familiar  with,  and  have  since  frequently 
pointed  out  to  many  of  my  medical  friends  and  pupils  a  peculiar 
form  of  deafness,  in  which  the  membrani  tympani  had  fallen  in 
towards  the  inner  wall  of  the  middle  ear, — had  lost  much  of  its 
vibratory  power,  and  in  which,  when  examined  under  a  good  light, 


THE  GERMAN  AND  FRENCH  SCHOOLS.        29 

the  handle  of  the  malleus  may  be  seen  appearing  to  press  outwards 
in  strong  relief.  In  this  affection,  which,  I  have  reason  to  believe, 
is  very  often  mistaken  for  nervous  deafness,  we  have  what  may  be 
termed  short  hearing,  from  an  alteration  in  the  vibratory  membrane 
of  the  ear,  in  like  manner  as  we  have  slioH  sightedness,  or  myopia, 
sometimes  arising  from  a  peculiar  alteration  in  the  curve  of  the 
cornea.  I  find,  however,  upon  carefully  perusing  the  paper  of  Cle- 
land,  that  he  had  some  idea  of  what  I  have  here  described,  and  of  its 
being  produced,  as  I  have  known  it  to  be  in  some  cases,  by  accident. 
"  There  is,"  he  says,  "  another  kind  of  deafness,  which  proceeds  from 
a  violent  clap  of  thunder,  noise  of  a  cannon,  or  the  like.  In  this 
case  it  is  probable  that  the  position  of  the  membrana  tympani  is 
altered,  being  forced  inwards  upon  the  small  bones,  and  so  becomes 
concave  outwardly.  In  this  case  no  vibration  of  sound  will  be  com- 
municated to  the  drum  until  the  membrane  has  recovered  its  natural 
position."^ 

During  the  remaining  half  of  the  eighteenth  century  I  have  little 
to  record ;  the  art  does  not  appear  to  have  advanced  a  single  step,  • 
either  in  Britain  or  any  other  part  of  Europe.  Books  and  essays 
were  written,  no  doubt,  but  their  authors  added  little  to  the  labors  of 
their  predecessors.  The  great  majority  of  these  writings  emanated 
from  the  German  press,  as,  for  instance,  those  of  Gniditsch,  Wild- 
berg,  Milloradovics,  Kritter,  Arnemann,  and  Lentin.  Of  the  French 
school  may  be  mentioned  Desmonceaux  and  Leschevin ;  the  writings 
of  the  latter  will  be  found  in  the  Memoirs  of  the  Royal  Academy  of 
Surgery  of  Paris  for  1763.  Having  lately  had  occasion  to  examine 
this  dissertation,  which  was  undoubtedly  the  best  of  its  day,  I  am 
bound  to  say  that  the  lavish  praise  bestowed  upon  it  by  the  French, 
and  the  severe  criticisms  of  the  German  writers,  within  the  last  few 
years,  were  alike  unmerited. 

Up  to  the  close  of  the  eighteenth  century  no  special  work  upon 
the  diseases  of  the  ear  had  appeared  in  England,  with  the  exception 
of  the  translation  of  Du  Verney,  to  which  I  have  already  alluded. 
English  works  have,  it  is  true,  been  enumerated  by  foreign  writers, 
but  they  were  not  written  upon  the  diseases  properly  so  called,  but  on 
the  congenital  defects  of  the  organ  of  hearing.  These  I  have  specified 
in  that  portion  of  the  work  relating  to  the  instruction  of  the  deaf  and 
dumb. 

In  1788,  Dr.   Peter  Degravers,  who  styled  himself  Professor  of 

'  Philosophical  Transactions,  vol.  xli.  part  ii.  p.  850. 


30   AURAL  SURGERY  IN  THE  EIGHTEENTH  CENTURY. 

Anatomy  and  Physiology,  published  in  Edinburgh  "  A  Treatise  on 
the  Human  Ear,"  as  an  Addenda  to  the  second  edition  of  his 
"  Physico-Medical  and  Ohirurgical  Treatise  on  the  Human  Eye." 
This  tract  consists  of  62  pages,  and  is  divided  into  three  Parts : — 
The  Anatomical  Exposition ;  The  Physiological  Inquiry  into  the 
Origin  of  Sounds ;  and  the  external  and  internal  Disorders  of  the 
Ear.  The  work,  though  very  much  beneath  that  of  the  author's 
Observations  on  the  Diseases  and  Operations  of  the  Eye,  is  yet  in- 
telligible enough,  and  came  up  fully  to  the  state  of  knowledge  on 
aural  surgery  at  that  time.  It  is  generally  believed  that  Sir  Astley 
Cooper  was  the  first  person  who  perforated  the  menibrana  tympani. 
Degravers,  however,  tells  us  in  his  essay  that  he  completely  removed 
the  tympanal  membrane  in  one  case  ;  and  again  he  says  : — "  I  incised 
the  membrana  tympani  of  the  right  ear  with  a  sharp,  long,  but  small 
lancet.     I  left  the  patient  in  that  state  for  some  time,  and  afterwards 

observed  that  it  had  reunited I  incised  again  the  mem- 

brani  tympani  of  the  right  ear  but  crucially ;  and  on  removing  the 
.parts  of-  the  membrane  incised,  I  discovered  some  of  the  ossicula, 
which  I  brought  out." 

During  the  eighteenth  century  the  anatomy  of  the  organ  of  hear- 
ing was  further  studied  by  Valsalva,  in  his  work  "  De  Aure  Humana 
Tractatus,"  published  at  Bonn  in  1704;  and  by  I.  F.  Cassebohm, 
whose  book,  "  Tractatus  Quatuor  Anatomici  De  Aure  Humana,  Tribus 
Figurarum  Tabulis  Illustrati,"  appeared  in  1734.  These  writings, 
with  subsequently  those  of  Scarpa,  Soemmering,  and,  in  later  times,  of 
Arnold,  have  rendered  the  anatomy  of  the  organ  of  hearing  very  com- 
plete. Mr.  T.  Wharton  Jones  has  embodied  all  that  was  known  upon 
the  subject  when  he  wrote  the  article  "  Organ  of  Hearing  "  in  the  Cy- 
clopaedia of  Anatomy  in  1838. 

The  members  of  the  Medical  Society  of  London,  instituted  in 
1773,  and  composed  of  the  physicians,  surgeons,  and  apothecaries  of 
that  time,  were  not  insensible  to  the  low  condition  in  which  aural 
medicine  stood  toward  the  end  of  the  last  century,  and  in  their  valu- 
able memoirs  will  be  found  some  scattered  notices  upon  the  diseases 
of  the  ear,  from  the  pens  of  the  president.  Dr.  Sims,  as  well  as  from 
Mr.  Houghton,  Dr.  Zeucker,  a  Prussian,  and  Dr.  Roslet  of  Ostend. 
Most  of  these  papers  contained  post  mortem  examinations  of  cases  of 
deafness,  a  practice  that,  with  the  honorable  exception  of  Mr.  Toyn- 
bee,  has  not,  I  regret  to  say,  been  followed  up,  and  very  much  to  the 
detriment  of  aural  medicine.     In  Dr.  Sims'  essay  he  entered  into  a 


QUACKS    AND     QUACKEEY.  ,  31 

physiological  discussion  regarding  the  nature  of  the  Eustachian  tube, 
the  object  of  which  was  to  show,  that  while  we  heard  all  external 
sounds  through  the  meatus  externus,  we  were  conscious  of  our  own 
voice  only  through  the  Eustachian  tube.  The  practical  part  of  his 
paper  is,  however,  exceedingly  valuable,  particularly  with  respect  to 
the  manner  of  pressing  air  through  the  tube  into  the  middle  ear,  by 
closing  the  mouth  and  external  nares,  and  then  making  a  forced  ex- 
piration ;  but  this  had  been  already  explained  by  Cleland  in  1741. 

In  1775,  James  Graham  published  in  London  "  Thoughts  on  the 
Present  State  of  the  Practice  in  Disorders  of  the  Eye  and  Ear,"  8vo. ; 
and  in  1780,  J.  Elliot  made  his  "  Philosophical  Observations  on  the 
Senses  of  Vision  and  Hearing."  Still,  at  the  conclusion  of  the  last, 
and  about  the  beginning  of  this  century,  aural  surgery  and  medicine 
were  at  a  very  low  ebb,  particularly  in  Great  Britain.  This  want  of 
knowledge  by  the  regular  practitioner  upon  the  subject  of  diseases  of 
the  ear  was,  however,  soon  taken  advantage  of,  not  only  by  professed 
quacks  and  nostrum-mongers,  but  by  the  electrical,  galvanic,  and 
magnetic  doctors  of  that  day,  who  corresponded  to  the  homoeopaths, 
hydropaths,  and  mesmerisers  of  the  present.  At  the  period  to  which 
I  allude,  galvanism,  magnetism,  and  electricity,  together  with  the 
celebrated  metallic  tractors,  were  applied  to  the  ears  of  persons  labor- 
ing under  deafness,  and  numerous  and  wonderful  were  the  cures 
vaunted  in  the  periodicals  of  the  day,  as  having  been  effected  by 
these  remedies  ; — cures  almost  equalling  those  lately  said  to  be  per- 
formed on  the  eye  by  prussic  acid :  while  secret,  but  never-failing 
acoustic  drops,  stimulating  embrocations,  and  the  like  impostures, 
were  pawned  upon  the  public  by  all  those"  who  had  ingenuity  and 
effrontery  enough  to  make  money  after  that  fashion.  And  here  let 
us  for  a  moment  digress  from  the  direct  course  of  our  subject  to 
answer  a  question  that  is  often  propounded — Why  is  it  that  the  em- 
piric and  the  pretender,  either  licensed  or  unlicensed, — for  in  these  days 
there  are  as  many  and  as  impudent  quacks  with  as  without  diplomas, 
— why  is  it,  one  is  often  asked,  that  the  charlatan  frequently  suc- 
ceeds in  practice  better  than  the  honest  practitioner  ?  By  the  term 
success,  we  do  not  mean  professional  success  in  his  art,  but  pecu- 
niary success  in  life,  and  esteem  among  those  with  whom  money 
"makes  the  man."  Now  although  we  cannot  always  answer  this 
query,  nor  would  the  same  explanation  be  applicable  to  every  in- 
stance, we  can,  however,  assert  one  fact,  which  in  a  great  measure 
contributes  to  the  success  of  the  quack,  and  it  is  this, — the  hearty 


32  QUACKS    AND     QUACKERY. 

response  of  his  patients  to  the  lesson  picked  up  from  the  showman — 
"  speak  a  good  word  to  your  friends  outside."  Let  any  well-educated 
honest  practitioner  be  called  on  to  treat  an  urgent  and  alarmingly 
dangerous  case,  where  insidious  death  stands  at  the  sick  man's  door 
— let  him  bring  all  the  powerful  acquirements  of  long  years  of  patient 
study  and  observation  of  disease — his  anatomical  and  pathological 
knowledge — an  eye  practised  to  disease,  and  a  head  stored  with  the 
sound,  rational,  scientific,  practical  principles  of  his  art — let  him  add 
to  this  the  kindness  of  a  friend,  nay,  often  the  benevolence  of  a  bene- 
factor— let  him  pass  anxious  days  and  sleepless  nights  watching  each 
turn  of  disease  in  his  patient,  and  ministering  to  every  of  the  many 
wants  that  attend  the  bed  of  lingering  sickness — let  him  do  all  this, 
and  finally  (under  Providence)  restore  the  patient  to  health  and  to  his 
friends — stand,  as  we  may  say,  between  the  living  and  the  dead, 
beckon  back  the  approaching  king  of  terrors,  and  give  again  to  so- 
ciety a  valuable  life,  and  to  the  trembling  anxious  family  their  only 
earthly  means  of  support — what  is  his  reward  ?  He  is,  generally  at 
least,  paid  his  fee,  and  the  patient  and  his  friends  are  generous 
enough  to  say  they  feel  grateful  for  all  his  kind  attention,  for  we  will 
not  curtail  it  of  whatever  good  feeling  may  be  shown  on  the  occa- 
sion. But  compare  this  with  a  patient  who  imagines  he  is  cured  of 
an  imaginary  disease  by  a  water  doctor,  or  an  atom  doctor,  an  electro- 
biologist,  a  mesmeriser,  or  a  magnetiser, — is  he  not  immediately  con- 
verted into  a  partisan  ? — does  he  not  become  a  missionary  for  the 
nostrum-monger  ? — does  he  not  go  about  from  house  to  house  detail- 
ing the  miracle  of  his  cure,  the  skill  of  the  doctor,  the  horrors  of  the 
regular  practitioner,  and  the  great  benefit  conferred  upon  mankind 
by  being  converted  into  hydraulic  machines  ;  or  expressing  his  sur- 
prise that  people  will  go  about  their  ordinary  business  "  clothed  and  in 
their  right  mind,"  like  the  man  from  whom  the  seven  devils  were  cast 
out,  instead  of  being  wrapped  in  a  wet  sheet,  or  enjoying  a  sitz-bath 
for  ten  houi's  a  day  :  while  others  will  wait  upon  you  specially,  to  beg 
and  entreat  you  will  not  convert  your  poor  stomach  into  an  apothe- 
cary's shop  by  taking  all  that  "  doctor's  stulF,"  instead  of  procuring 
rest  and  ease  to  all  your  ills  by  just  such  an  anodyne  as  would  be 
formed  by  pouring  one  drop  of  laudanum  into  the  Bosphorus,  where 
it  leaves  the  Euxine,  and  drinking  a  thimble-full  of  the  same  water 
where  it  enters  into  the  Mediterranean !  But,  not  content  with  this, 
these  medical  missionaries  abuse '  all  regular  practitioners,  and  often 


CHESELDEN    AND    COOPER.  33 

force  (for  liumanity's  sake,  as  they  say)  tlie  charlatan  upon  the 
patient,  who  then  trusts  to  his  address  for  future  fame  and  profit. 

In  1793  Jasser  revived  the  old  operation  of  perforation  of  the 
mastoid  process  for  the  purpose  of  injecting  the  middle  ear ;  but  as 
the  success  attending  this  procedure  must  be  very  doubtful,  and  the 
hazard  very  great,  it  is  never  resorted  to  in  the  present  day. 

Several  experiments  had  been  tried  by  anatomists  and  physiologists 
upon  dogs  and  other  animals,  in  order  to  discover  whether  the  func- 
tion of  hearing  could  be  carried  on  with  a  perforate,  or  imperfect 
membrana  tympani.  These  investigations  upon  the  lower  animals 
being  deemed  inconclusive,  Mr.  Cheselden,  the  father  of  English 
surgery,  proposed  to  experiment  in  this  matter  upon  the  living 
human  subject,  and  for  this  purpose  a  condemned  criminal  was  par- 
doned, on  condition  of  submitting  to  the  operation !  but  a  popular 
outcry  prevented  its  being  put  in  force  !^  Some  years  afterwards, 
Sir  Everard  Home,  in  his  article  upon  the  muscularity  of  the  mem- 
brana tympani,  having  expressed  his  desire  to  know  the  result  of  per- 
foration or  destruction  of  this  membrane,  Mr.,  afterwards  Sir  Astley, 
Cooper,  published  a  letter  in  the  Philosophical  Transactions  for  the 
year  1800,  entitled,  "  Observations  on  the  Effects  which  take  place 
from  the  Destruction  of  the  Membrana  Tympani  of  the  Ear." 
Although  this  paper  did  not  advance  oui*  practical  knowledge  upon 
the  subject,  yet  it  called  the  attention  of  British  surgeons  to  the 
treatment  of  this  important  organ,  and  put  an  end  to  a  very  gene- 
rally received  notion  among  the  profession,  that  hearing  would  be 
totally  lost  on  the  opening  of  the  membrana  tympani ;  notwithstand- 
ing that  a  couple  of  hundred  years  ago  it  was  believed  by  anatomists 
that  an  apertui'e  existed  in  this  structure,  as  a  normal  condition  during 
life. 

In  the  following  year  Cooper  published  an  essay  in  the  same  work 
on  the  perforation  of  the  membrana  tympani,  as  a  means  of  removing 
deafness  caused  by  obstruction  of  Jhe  Eustachian  tube,  and  a  conse- 
quent want  of  vibration  in  the  tympanal  membrane.  This  paper 
commenced  a  new  era,  and  opened  up  a  wide  field  in  am'al  surgery. 
Like  all  discoveries  in  medicine,  however,  it  was  at  the  time,  and  in 

^  This  case  is  referred  to  in  Walpole's  Reminiscences,  where  it  is  stated  that  the 
criminal  was  Cheselden's  cousin,  and  that  he  was  pardoned  at  the  intercession  of  Lady 
Suffolk  (mistress  to  George  II.),  who,  being  herself  deaf,  wished  to  have  the  experiment 
tried.  The  surgeon  lost  the  royal  favor,  it  is  said,  by  the  circumstance.  This  story 
may,  however,  be  but  one  of  the  petty  scandals  of  the  day. 

3 


34  PERFOKATION    OP    THE    MEMBRANA    TYMPANI. 

other  hands,  too  frequently  had  recourse  to,  and  often  misapplied. 
The  brilliancy  of  this  operation,  and,  in  some  instances,  its  instanta- 
neous effects,  urged  men  to  employ  it  who  were  totally  ignorant  of  its 
application,  as  well  as  of  the  structures  and  diseases  of  the  organs  of 
hearing  generally ;  so  that  it  soon  fell  into  disuse,  and  although 
recommended  by  this  high  authority,  the  superior  instruments  we 
now  possess  of  diagnosing  with  greater  accuracy  the  condition  of  the 
middle  ear,  and  its  internal  faucial  aperture,  by  means  of  the  air- 
douche,  and  also  owing  to  the  comparatively  few  cases  of  deafness 
solely  depending  on  closure  or  stricture  of  the  Eustachian  tube,  have 
rendered  its  performance  much  less  frequently  necessary  than  was  at 
first  supposed.  Himley,  Itard,  Deleau,  Fabrigi,  and  others,  improved 
and  modified  the  instruments  and  the  Operation  of  Cooper.  This 
may  be  termed  the  third  epoch  in  our  art ;  the  first  two  being  the 
application  of  the  speculum  by  Fabricius,  and  the  introduction  of 
Eustachian  catheterism  by  Cleland. 

I  cannot  conclude  this  notice  of  Sir  Astley's  improvement,  without 
quoting  the  pertinent  and  judicious  remarks  with  which  he  closes  his 
memoir — advice  and  remarks  which,  I  regret  to  add,  have  been  but 
little  attended  to,  but  which  are  as  applicable  to  the  present  time  as 
they  were  to  the  period  when  they  were  written. 

"  I  hope  others  will  be  induced,"  he  says,  in  alluding  to  the  success 
of  his  operation,  "to  second  my  feeble  efforts,  and  to  direct  their 
attention  to  a  subject  which  appears  to  be  of  the  highest  importance, 
and  to  have  been  too  much  neglected  by  medical  men ;  for  a  know- 
ledge of  the  structure  of  the  ear  is  by  no  means  general  in  the  pro- 
fession, and  still  less  are  its  diseases  understood.  A  prejudice  has 
prevailed  that  the  ear  is  too  delicate  an  organ  to  be  operated  upon, 
or,  as  it  is  commonly  expressed,  tampered  with ;  and  thousands  have 
thus  remained  deaf  for  the  rest  of  their  lives,  who  might  have  been 
restored  to  their  hearing  had  proper  assistance  been  early  applied." 

Not  to  burden  the  reader  with  too  minute  and  extended  a  bibliology 
or  critical  review,  I  will  now  compress  the  history  of  our  art,  with  fcAV 
exceptions,  into  the  labors  of  British  aurists.  The  well-marked  in- 
flammatory diseases  of  parts  of  the  auditory  apparatus,  such  as  the 
auricle,  external  tube,  and  tympanum,  were  generally  treated,  by  all 
well-educated  surgeons,  as  in  the  present  day,  by  strict  antiphlogistic 
means,  the  local  abstraction  of  blood,  purging,  and  counter-irritation ; 
but  here  the  judicious  interference  of  art  ceased ;  and  it  would  have 
been  well  if  all  further  meddling  had  been  avoided ;  but  laudanum 


S  A  U  N  D  E  K  S.  35 

was  regarded  as  a  panacea  in  all  cases  of  ear-ache,  no  matter  from 
what  cause  it  may  have  arisen ;  and  drops,  oils,  and  liniments,  some 
of  them  of  the  most  caustic  natm'e,  were,  without  mercy  and  without 
discrimination,  pom-ed  into  the  external  meatus  by  those,  who  like  the 
regicide  of  old — 

"  Stole 
With  juice  of  cursed  hebenon  in  a  vial, 
And  in  the  porches  of  the  ears  did  pour 
The  leperous  distilment." 

First  upon  the  list  of  British  writers  upon  the  acoustic  apparatus 
and  its  diseases  stands  John  Cunningham  Saunders,  the  distinguished 
oculist,  and  the  founder  of  the  London  Infirmary  for  Diseases  of  the 
Eye,  on  whose  merits,  as  an  original  observer,  a  sound  practical  sur- 
geon, and  a  critical  anatomist,  I  need  not  expatiate.  His  work, 
"  The  Anatomy  of  the  Human  Ear,  illustrated  by  a  series  of  engrav- 
ings, of  the  natural  size ;  with  a  Treatise  on  the  Diseases  of  that 
Organ,  the  Causes  of  Deafness,  and  their  proper  Treatment,"  was 
published  in  1806 ;  and  although,  as  I  have  said,  he  availed  him- 
self of  the  labors  of  Du  Verney,  still  to  Saunders  we  are  indebted  for 
the  first  special  English  work  of  any  merit  upon  this  subject,  and  to 
him  the  various  charlatans  that  have  ventured  to  set  forward  their 
ideas  in  print  are  indebted  for  the  mine  from  which  they  drew  the 
material  of  their  various  and  voluminous  publications.  Saunders,  as 
an  aurist,  has  been  unjustly  dealt  with :  he  wrote,  not  merely  in  ac- 
cordance with,  but  beyond  the  knowledge  of,  his  time,  and  Kramer 
not  only  criticises  his  work  with  too  great  severity,  but  denies  it  the 
place  which,  in  a  chronological  point  of  view,  it  deserves.  This  may, 
however,  be  accounted  for  by  Kramer's  having  quoted  from,  as  per- 
haps he  only  had  access  to,  the  third  edition,  published  in  1829,  just 
nineteen  years  after  Mr.  Saunders's  death.  The  practical  portion  of 
the  work  consisted  of  the  history  and  treatment  of  the  diseases  of  the 
meatus  externus,  and  those  of  the  tympanum,  of  the  obstruction  of  the 
Eustachian  tube,  and  of  the  diseases  of  the  internal  part  of  the  ear, 
to  which  are  added  cases  of  incipient  nervous  deafness  successfully 
treated.  The  plates  are  worthy  of  inspection,  and  were  evidently 
drawn  from  recent  dissections.  Saunders  possessed,  in  addition  to 
his  originality,  honesty  and  general  attainments  in  the  science  of  ana- 
tomy and  surgery,  this  great  requisite  for  an  aurist, — that,  having 
also  applied  himself  to  the  study  of  diseases  of  the  eye,  he  had  thus 
acquired  habits  of  minute  observation  and  delicate  manipulation,  with- 


db  CURTIS    AND    HIS    FOLLOWERS. 

out  which  no  man  will  ever  attain  to  eminence  in  either  art.  More- 
over, the  analogy  which  exists  between  the  diseases,  as  well  as  the 
anatomy  and  physiology  of  these  two  organs,  enabled  him  to  bring 
to  the  study  of  the  ear  the  rational  principles  of  medicine  then  esta- 
blished in  the  treatment  of  ocular  affections. ' 

For  six  or  eight  years  we  hear  nothing  of  aural  surgery  in  Great 
Britain,  and  our  space  will  not  permit  of  our  even  enumerating  the 
names  of  the  different  Continental  writers  for  the  first  twenty  years 
of  the  nineteenth  century.  Cooper's  more  extended  and  more  lucra- 
tive line  of  practice  caused  him-,  to  relinquish  aural  surgery, — this, 
and  the  untimely, death  of  Saunders,  seem  to  have  cast  a  veil  over 
this  branch  of  knowledge  in  these  kingdoms. 

In  the  years  1815  and  1817  we  find  two  special  works  on  aural 
medicine;  of  the  first  of  these,  '•'•  Dissertatio  de  Aure  Humana  et 
ejus  Morbis,"  an  inaugural  essay,  published  by  Mr.  Ball  at  Edin- 
burgh, there  is  little  even  to  criticise  ;  and  the  second  was  the  earliest 
work  of  the  since  far-famed  John  Harrison  Curtis.  Let  us  read  its 
high-sounding  title :  "A  Treatise  on  the  Physiology  and  Diseases  of 
the  Ear,  containing  a  comparative  view  of  its  Structure,  Functions, 
and  of  its  various  Diseases,  arranged  according  to  the  Anatomy  of 
the  Organ,  or  as  they  affect  the  external,  the  intermediate,  and  the 
internal  Ear."  Let  us  draw  from  the  writings  of  a  foreigner  the 
opinion  that  a  man  of  honesty  and  practical  experience  formed  of 
this  and  the  author's  subsequent  works.  "Curtis,"  says  the  writer, 
"  treats  every  discharge  from  the  ear  exclusively,  and  in  a  summary 
way,  by  means  of  astringents  ;  obstructions  of  the  Eustachian  tube, 
with  emetics  and  perforation  of  the  membrana  tympani ;  whilst,  in 
spite  of  all  the  entreaties  of  Saissy,  he  has  never  once  practised 
catheterism  of  the  Eustachian  tube  on  the  living  subject.  He  makes 
tinnitus  the  chief  symptom  of  nervous  deafness,  which  he  treats  with 
purgatives,  especially  calomel,  as  long  as  the  strength  of  the  patient 
holds  out."  "  In  all  doubtful  cases  the  chief  attention  is  directed 
merely  to  ascertain  whether  the  liquor  Cotunnii  be  partially  or  totally 
deficient !  !  or  whether  hardened  wax  exist  in  the  meatus."  "  In  the 
otitis  of  children  he  sticks  opium  into  the  affected  ear,  &c.,  so  that 
throughout  all  his  writings  nothing  but  the  most  crude  empiricism  is 
to  be  met  with ;  and  yet  among  his  compatriots,  as  well  as  abroad, 
Curtis  generally  possesses  the  reputation  of  being  a  distinguished 
aurist."  And  one  of  the  first  English  medical  periodicals  of  the  day 
thus  expresses  its  admiration  of  the  same  person :  "  Mr.  Curtis,  in 


THE    WRITINGS     OF    WRIGHT    AN  D^  WEBSTER.  37 

his  Treatise  on  the  Physiology  and  Pathology  of  the  Ear,  has  appro- 
priated the  wliole  of  Mr.  Saunders's  essay.  The  exact  words,  indeed, 
have,  in  some  instances,  been  changed,  but  the  plagiarism  is  too  mani- 
fest to  escape  even  the  most  inattentive  reader.  To  this  paraphrase, 
of  Mr.  S.'s  work,  Mr.  Curtis  has  added  some  things  from  other 
authors,  and  some  histories  of  cases  treated  by  himself  (of  course  all 
most  successfully),  and  has  thus  concocted  a  treatise  which,  with  sin- 
gular effrontery,  he  has  put  forth  as  entirely  of  his  own  composition, 
and  as  containing  the  results  of  his  own  practice.  This  work  has 
now,  for  a  period  of  about  twenty  years,  been  forced  upon  the  atten- 
tion of  the  public  by  the  advertisements  of  successive  editions ;  and 
it  is  a  melancholy  fact,  that  there  should  have  been  found  editors  of 
medical  journals  either  so  ignorant  or  so  careless  as  to  lavish  com- 
mendation on  such  a  production." 

Almost  in  a  similar  category  may  be  classed  the  writings  of  Wil- 
liams, surnamed  the  nostrum-monger ;  and  also  those  of  Stephenson 
and  of  Wright,  "  New  Observations  on  the  Diseases  of  the  Eye  and 
Ear,"  1817.  The  latter  followed  something  of  the  plan  laid  down  by 
Curtis,  of  simply  recojnjjosing  the  words  of  his  first  work ;  for  as  to 
new  ideas,  there  were  none,  nor  old  ones  to  add  them  to.  In  order 
to  form  either  a  new  edition,  or  a  new  book,  we  find  the  changes  rung 
to  the  following  tunes  for  about  ten  or  eleven  years :  "  An  Essay  on 
the  Human  Ear,  its  Anatomical  Structure,  and  Incidental  Com- 
plaints," 1819;  "The  Aurist,  or  Medical  Guide  for  the  Deaf," 
1825 ;  "  Plain  Advice  for  all  Classes  of  Deaf  Persons,  the  Deaf  and 
the  Dumb,  and  those  having  Diseases  of  the  Ear,  1826," — verily,  this 
must  have  been  a  popular  book ;  "  Observations  on  the  Effects  of 
Mercury  on  the  Organs  of  Hearing,  and  the  improper  use  of  it  in 
cases  of  Nervous  Deafness,"  1827 ;  "  On  the  Varieties  of  Deafness 
and  Diseases  of  the  Ear,  with  proposed  Methods  of  relieving  them," 
1829,  To  these  was  added,  "The  Present  State  of  Aural  Surgery," 
together  with  three  or  four  others,  all  by  the  redoubted  Mr.  William 
Wright.  With  these  productions  may  be  classed  those  of  Webster, 
Thornton,  and  Fletcher,  works  similar  in  substance  and  composition, 
although,  perhaps,  not  so  flagrant  in  plagiarism.  Among  the  writers 
of  that  period,  and  with  some  even  down  to  the  present,  it  was  usual 
to  preface  whatever  they  had  to  offer  to  public  notice  as  a  cure  for 
deafness  by  a  lengthened  description  of  the  structure  and  physiology 
of  the  ear,  copied  from  some  of  the  general  or  special  works  upon 
anatomy.     Thus,  when  one  of  the  persons  just  alluded  to  wished  to 


38  HE;PWORTH    AND    GARDNER. 

advertise  a  new  instrument,  made  to  fit  the  back  of  the  auricle,  for 
the  purpose  of  collecting  sound,  we  find  that  there  issued  from  the 
London  press  in  1836,  "A  new  Sind familiar  Treatise  on  the  Struc- 
ture of  the  Ear  and  on  D.eafness,  by  A.  W.  Webster,  inventor  of  the 
Otaphone,  &c.  &c."  Among  the  illustrations  to  that  work  we  observe 
an  ill-executed  wood-cut,  of  a  very  ugly  and  misshapen  auricle,  but 
bearing  the  attractive  inscription  of  "Mozart's  Ear."  On  perusing 
the  text,  however,  we  discover  that  it  was  not  the  ear  of  the  great 
musician,  but  that  of  his  youngest  son,  "  which  resembled  that  of  his 
father !"  One  specimen  from  the  medical  portion  of  the  book  will 
suffice :  "  The  membrane  of  the  tympanum,  which  I  have  before 
described  as  presenting  the  appearance  of  a  large  opal  bead,  was 
frequently  reduced,  both  in  size  and  color,  to  the  resemblance  of  a 
mustard  seed,  the  burning  substances  which  had  been  put  within  the 
ear  having  efiected  that  change." 

But  it  was  not  alone  among  the  instrument  venders  and  itinerant 
aurists  that  ignorance  and  quackery  were  to  be  found.  About  eight 
years  ago  I  was  sent  a  book,  bearing  the  following  title,  but  without 
a  date :  "  The  Causes,  Symptoms,  and  Treatment  of  Nervous  Deaf- 
ness, Inflammation  of  the  Eye,  and  Indigestion,  popularly  treated  by 
J.  D.  Hepworth,  late  Surgeon  to  the  Leeds  General  Eye  and  Ear 
Infirmary,"  In  the  anatomical  description  he  says,  the  membrana 
tympani  is  "  of  a  dry  and  brittle  tissue,  without  fibres  or  blood- 
vessels." Nervous  deafness  is  ascribed  to  obstructions  in  the  secre- 
tion of  the  fluid  of  the  vestibule  ;  and  hardness  of  hearing,  following 
measles  or  scarlet  fever,  to  chronic  inflammation  of  the  membrane  of, 
and  deposits  of  lymph  within,  the  semicircular  canals !  Surely 
foreigners  might  well  criticise  English  writers  on  aural  medicine 
when  they  read  such  statements  as  the  foregoing. 

Somewhat  of  the  same  character  is  the  work  of  Dr.  Gardner  on 
Deafness,  consisting  of  152  pages,  entirely  devoted  to  the  anatomy 
of  the  ear,  with  half  a  page  at  the  end  explanatory  of  the  contents 
of  the  second  part,  upon  the  Pathology  and  Treatment  of  Diseases  of 
the  Ear,  but  which  we  have  not  yet  seen.  This  is  the  only  book  upon 
the  subject  which  has  issued  from  the  Dublin  press.  It  appeared 
in  1828.' 

'  Its  lengthy  and  attractive  title  runs  thus :  "  A  Treatise  on  Deafness ;  its  Causes,  Pre- 
vention, and  Cure;  the  Physiology  and  Anatomy  of  the  Ear;  the  Uses  of  the  different 
parts  for  the  modification  and  conveying  of  Sounds  to  the  seat  of  Hearing;  the  different 
classes  of  Diseases  incident  to  the  different  parts,  and  what  class  of  Medicines  are  best 


BUCHANAN.  39 

There  is  one  English  writer  whom  we  would  rescue  from  the  criti- 
cism which  has  been  already  applied  to  his  predecessors.  In  1823, 
Mr,  Thomas  Buchanan,  an  intelligent  sui'geon  of  Hull,  published  an 
engraved  representation  of  the  anatomy  of  the  human  ear,  to  which 
were  added  some  surgical  remarks  on  Eustachian  catheterism,  toge- 
ther with  an  account  of  the  operation  of  puncturing  the  membrana 
tympani,  and  concluded  with  a  synoptical  table  of  diseases  of  the 
ear.  Mr.  Buchanan  put  forward  many  fallacies  in  his  work,  particu- 
larly with  regard  to  the  physiological  uses  and  diseases  of  the  external 
meatus ;  and  in  a  literary  point  of  view  he  seems  to  have  fallen  into 
the  snare  almost  peculiar  to  English  aurists,  for  within  a  couple  of 
years  he  followed  up  whatever  success  may  have  attended  his  first 
publication  by  producing  two  other  works,  one,  the  "Illustrations," 
and  the  other,  "  The  Guide  to  Acoustic  Surgery ;"  and  in  1828 
appeared  a  foiu'th  work,  "  Physiological  Illustrations  of  the  Organs 
of  Hearing,  more  particularly  of  the  secretion  of  cerumen,  and  its 
effects  in  rendering  Auditory  Perception  accurate  and  acute."  Bu- 
chanan, however,  deserves  our  commendation  and  commands  our 
respect  as  being  the  fii'st  English  writer  who,  since  the  days  of  Saun- 
ders and  Cooper,  based  his  works  upon  a  knowledge  of  the  principles 
of  anatomy  and  surgery ;  and  to  him  we  are  indebted  for  an  improve- 
ment in  the  inspector  am'is,  by  means  of  which,  as  I  have  already 
explained  at  page  27,  artificial  light  may  be  transmitted  through  the 
meatus  to  the  membrana  tympani. 

About  the  year  1820  some  notices  of  aural  diseases  appeared  in 
the  medical  periodicals,  and  foremost  among  the  writers  of  these 
stands  Mr.  Henry  Earle,  whose  short,  but  accurate  and  practical 
observations  upon  some  diseases  of  the  external  meatus,  published  in 
the  London  Medico- Chirm-gical  Transactions,  are  well  worthy  of 
perusal.  The  Lancet  and  Medical  Gazette  likewise  contained  some 
detached  notices,  and  the  details  and  pathological  appearances  of 
several  cases  of  the  diseases  of  the  organs  of  hearing. 

Within  the  last  twenty  years  there  have  appeared  three  small  works 
upon  the  anatomy  and  physiology  of  the  organ  of  hearing,  by  Mr. 

calculated  to  restore  the  several  parts  to  their  proper  functions;  also,  a  representation  of 
the  cases  out  of  the  reach  of  human  aid.  The  map  of  the  internal  ear  will  show  the 
precise  situation  of  the  most  important  parts,  to  facilitate  the  study  of  its  anatomy,  and 
should  be  referred  to  in  the  perusal  of  this  work.  By  T.  Gardner,  Esq.,  M.D.,  Aurist, 
and  Professor  of  Physiology  of  the  Ear.  Dublin  :  Printed  by  J.  M'MuUen,  55  Exchange 
Street,  1828." 


40  THEFRENCHSCHOOL. 

Swan,  Mr.  David  Tod,  and  Mr.  Caswall.  The  first  of  these,  from 
the  originality  of  its  ideas,  and  the  speculative  theory  of  its  author, 
justly  attracted  attention  in  an  anatomico-physiological  point  of  view, 
yet  neither  it  nor  the  other  two  with  which  it  is  associated  should 
have  been  enumerated  in  the  history  of  aural  surgery,  but  that  to 
each  were  afiixed  some  observations  upon  the  pathology  of  the  ear 
generally,  and  its  congenital  defects  in  particular.  These  observa- 
tions are,  however,  crude,  speculative,  and  unpractical.  I  may 
merely  mention  one  of  these  as  a  sample  of  the  rest : — Mr.  Tod 
proposes  as  a  remedy  for  congenital  deafness  depending  on  derange- 
ment of  the  structures  in  the  tympanum,  the  introduction  of  such 
acrid  substances  as  ammonia,  cantharides,  and  the  mineral  acids,  in 
order  to  produce  such  an  inflammation  as  may  rouse  into  activity  the 
dormant  powers  of  the  parts  contained  within  that  cavity ! 

The  splendid  discoveries  of  Laennec  with  regard  to  the  stethoscope, 
and  the  morbid  or  abnormal  sounds  produced  by  streams  of  air  pass- 
ing over  diseased  structures,  were  not  long  in  being  employed  as  a 
means  of  diagnosis  by  such  of  his  countrymen  as  had  devoted  their 
talents  and  energies  to  the  investigation  and  treatment  of  diseases  of 
the  ear.  Foremost  among  these  stood  Deleau,^  whose  works  first 
established  the  more  general  practice  in  Europe  of  the  introduction 
of  various  medicated  vapors,  as  well  as  fluid  injections,,  into  the 
middle  ear,  by  means  of  catheterism  of  the  Eustachian  tube,  a  mode 
of  treatment  since  so  extensively  employed  by  Kramer.  But  it  should 
not  be  forgotten  that  similar  means  were  used  in  England  nearly  a 
hundred  years  before,  by  Cleland  and  Wathan.  The  labors  of  Itard 
are  also  worthy  of  attention,  from  the  clearness  and  perspicuity  of 
his  views,  and  from  his  vast  experience  in  treating  the  inflammatory 
diseases  of  the  external  and  middle  ears,  yet  his  work  is  by  no  means 
devoid  of  those  prejudices  which,  even  to  the  present  day,  like  the 
amulets  of  a  by-past  age,  still  hang  round  books  upon  aural  surgery.^ 

To  these  may  be  added  the  works  of  M.  E.  Hubert  Valleroux,  the 
chief  of  which  is  the  "  Ussai  Theorique  et  Pratique  sur  les  Maladies 
del' Oreille."     Paris:  1846. 

We  now  turn  again  to  Germany,  where  we  find  aural  surgery  in  a 
higher  condition  than  in  any  other  country  in  Europe.     To  enumerate 

1  "  Recherches  Pratique  sur  les  Maladies  de  FOreille,  et  sur  le  Develloppement  de 
1 'Oreille  et  de  la  parole  chez  les  Surds  Muets."     Paris:  183S. 

2  "  Traite  des  Maladies  de  TOreille  et  de  I'Audition."  Tom.  ii.  Paris.  Second 
edition,  1842. 


THE    GERMAN    SCHOOL  —  KEAMER.  41 

all  the  books  and  pamphlets  on  diseases  of  the  ear  which  had  emana- 
ted from  the  German  press  since  1830  would  occupy  unnecessary- 
space  in  this  limited  outline,  but  the  principal  were  the  writings  of 
Kramer,  Lincke,  Schmalz,  and  Frank.  Dr.  W.  Kramer,  of  Berlin, 
published  his  first  work.  An  Essay  on  Chronic  Deafness,  in  1832,  and 
this  he  afterwards  enlarged  and  published  as  a  System  of  Aural  Sur- 
gery in  1836,  '■'■Die  Erkenntniss  und  Heilung  der  OhrenJcrank- 
heiten."  In  the  following  year  it  was  admirably  translated  into 
English  by  Dr.  J.  R.  Bennett,  and  is  decidedly  the  best  special  trea- 
tise on  the  subject  which  has  yet  appeared  in  this  country,  where  it 
exercised  a  most  salutary  influence  upon  the  diagnosis  and  treatment 
of  diseases  of  the  ear.  "  In  these  and  other  signs,"  writes  the  re- 
viewer of  Dr.  Bennett's  translation  in  the  British  and  Foreign  Medi- 
cal Review  for  1848,  "we  think  we  see  clear  indications  of  a  new 
era  in  acoustic  (?)  siirgery  in  this  country,  when  learning  and  science 
shall  assert  their  rights,  and  the  despicable  ignorance  and  impudent 
empiricism  which  have  hitherto  prevailed  shall  be  reduced  to  their 
proper  level.'"  The  truth  of  this  prediction  has  since  been  verified. 
Dr.  Kramer  subsequently  published  two  other  works  upon  the  ear, — 
"Beitrdge  zur  Ohrenheilkunde,"  in  1845,  the  major  part  of  which 
relates  to  the  statistics  of  aural  diseases, — to  which  I  shall  have  occa- 
sion to  refer  in  the  next  chapter, — and  "  Die  Olirenheilkunde  in  den 
Jahren  1849  %ind  1850."  Independent  of  the  luminous  descriptions, 
the  critical  acumen,  and  practical  observations,  and  the  consequent 
absence  of  quackery,  with  which  all  Dr.  Kramer's  writings  abound, 
the  chief  newness  and  originality  of  the  work,  which  has  been  trans- 
lated into  our  language,  consisted  in  the  details  of  cases  of  nervous 
deafness,  so  called,  said  to  have  been  cured  by  the  introduction  of 
etherous  vapor  and  other  gaseous  substances,  by  means  of  an  air- 
pump,  into  the  middle  ear,  through  the  Eustachian  tube.  By  thus 
fumigating  the  mucous  membrane  lining  the  drum,  it  was  said  that 
the  dormant  powers  of  the  auditory  nerve  were  stimulated  to  a  healthy 
action!  As  a  means  of  diagnosis  the  instrument  is  very  valuable, 
although  the  cases  in  which  it  is  required  are  comparatively  few  ;  but 
as  a  therapeutic  agent  the  Eustachian  pump  has  been  much  over- 
rated, and  if  benefit  to  any  extent  has  been  derived  from  introducing 
medicated  vapors  into  the  middle  ear,  it  is  more  than  probable  that  the 

'  In  the  admirable  periodical  from  which  the  above  has  been  extracted  will  be  found 
several  learned  articles  on  aural  medicine. 


42   THE  WORKS  OF  LINCKE,  SCHMALZ,  AND  FRANK. 

deafness  was  in  such  cases  caused  by  inflammation  of  the  cavity, 
upon  the  investing  membrane  of  which  those  minute  ramifications  of 
the  tympanic  plexus  of  the  glosso-pharyngeal  nerve  are  distributed, 
as  had  been  previously  remarked  by  Mr.  Swan,  Ten  years'  trial  and 
experience  has  not,  in  other  hands  at  least,  verified  the  anticipations 
which  were  entertained  from  a  perusal  of  the  Berlinese  aurist's 
opinions.  The  rage  for  fumigating  ears,  as  well  as  eyes,  has  for  the 
present  passed  by.  It  has  not  been  found  that  the  vapor  of  ether 
cures  cases  of  paralysis  or  impairment  of  the  function  of  the  audi- 
tory nerves,  no  more  than  the  fumes  of  prussic  acid  afibrd  relief  in 
amaurosis,  or  remove  cataracts  or  deep-seated  corneal  opacities.  A  new 
and  enlarged  edition  of  Dr.  Kramer's  book  on  the  Nature  and  Treat- 
ment of  Diseases  of  the  Ear  appeared  in  February,  1849,  the  author 
having  been,  he  says,  induced,  during  the  revolution  in  the  Prussian 
capital,  to  betake  himself  to  literature  and  the  revision  of  his  former 
writings.  From  the  tone  of  the  remarks  which  have  been  introduced 
into  this  new  edition,  one  is  inclined  to  think  the  writer's  labors  must 
have  been"  very  much  interrupted  by  the  fierce  battle  waging  around 
him ;  for  certainly  while  we  are  unable  to  discover  much  additional 
matter  of  value  therein,  we  are  not  a  little  surprised  at  the  style  of 
his  language,  so  uncourteous,  and  unsuited  to  a  scientific  subject. 
For  myself  I  cannot  but  feel  complimented  by  having  so  large  a  por- 
tion of  the  insertions  in  the  new  edition  of  this  work  devoted  to  the 
consideration  and  review  of  my  writings  and  opinions ;  but  for  the 
sake  of  literature  and  science,  and  the  friendly  feeling  which  has 
so  long  existed  between  the  Irish  and  German  schools  of  Medicine,  I 
cannot  but  regret  that  my  friend  did  not  discuss  the  questions  at  issue 
in  a  calmer  and  more  philosophic  mood. 

Dr.  C.  Gr.  Lincke,  of  Leipzig,  has  published  a  voluminous  work 
upon  Ear  Medicine,  consisting  of  two  volumes,  the  first  of  which, 
upon  the  Anatomy,  Physiology,  and  Pathology  of  the  Organs  of 
Hearing,  appeared  in  1837 ;  and  the  second,  on  the  Nosology  and 
Therapeutics  of  Diseases  of  the  Ear,  was  brought  out  in  1840.  This 
"  Handhuch  der  Theoretischen  und  Praktischen  OlirenJieilkunde," 
not  having  been  translated  into  the  language  of  this  country,  is  not 
as  well  known  as  it  deserves ;  for  although  it  does  not  contain  much 
original  matter,  is  rather  prolix  in  its  literary  analysis,  and  is,  per- 
haps, somewhat  too  minute,  not  to  say  fanciful,  in  its  division  and 
enumeration  of  diseases  of  the  ear,  yet  it  comprises  all  that  was 
known  upon  the  subject  of  aural  surgery  at  the  time  it  was  written, 


THE    MODERN     ENGLISH     SCHOOL. PILCHER.  43 

and  is  most  valuable  as  a  work  of  reference,  exhibiting  great  learning 
and  research. 

Another  industrious  compiler  is  Dr.  E.  Schmalz,  of  Dresden,  who 
has  written  several  useful  treatises  upon  this  subject,  and  whose  work 
upon  deaf-dumbness,  "  Kuze  G-escMchte  und  Statistik  der  Taub- 
stummenanstalten  und  des  Tauhstummenunterrichtes  nebst  voraus- 
gescMcJiten  arztlicTien  BemerTcungen  ilher  die  Taubstummheit,"  was 
one  of  the  best  when  it  appeared  in  1830.  The  other  principal 
works  of  this  author  are  his  "  Erfalirungen  ilber  die  KranhJieiten 
des  (xehores  und  iJire  Seilung,'"  published  in  1846,  and  "  Beitrdge 
sur  Grehd'r-und  jSprach-HeilJcunde,"  in  1848. 

Dr.  Martell  Frank,  of  Wiirtzburg,  issued  in  1845  his  "  Practische 
Anleitung  zur  Erkenntniss  und  Behandlung  der  Ohrenhranhheiten,'' 
&c.,  an  admirable  digest  of  the  subject,  abounding  in  references,  but 
not  containing  much  original  matter.  Like  the  works  of  the  two 
former  authors,  it  will  be  principally  useful  as  a  work  of  reference ; 
and  it  abounds  in  wood-cuts,  illustrating  the  different  instruments 
used  in  aural  surgery. 

I  shall  now  conclude  this  review  with  some  notices  of  modern  Eng- 
lish writers.  In  1837  the  Medical  Society  of  London  offered  a  prize 
for  the  best  essay  on  "  The  Structure,  Economy,  and  Diseases  of  the 
Ear."  This,  together  with  the  Fothergillian  Medal,  was  awarded  to 
Mr.  Pilcher  of  London,  who  in  the  following  year  published  his  essay 
as  "  A  Treatise  on  the  Structure,  Economy,  and  Diseases  of  the 
Ear."  It  is  divided  into  three  parts  :  the  Anatomy  and  Physiology, 
the  Abnormal  Conditions  and  Malformations,  and  the  Diseases  ;  the 
latter  consisting  of  171  pages  ;  a  truly  practical  work,  divested  of 
all  those  absurdities  which,  with  the  exception  of  those  of  Saunders 
and  Buchanan,  characterized  its  predecessors  in  the  British  metropo- 
lis. The  profession  would,  I  am  sure,  in  the  subsequent  editions  of 
this  work,  rather  see  the  author's  opinions  supported,  and  his  de- 
scriptions illustrated,  by  cases  occurring  under  his  own  observation, 
of  which  he  must  have  many,  than  those  supplied  by  his  friends,  or 
extracted  from  periodicals.  If  Kramer  led  the  profession  to  expect 
too  much  from  the  use  of  the  air-pump,  and  the  introduction  of  medi- 
cated vapor,  I  cannot  but  think  Mr.  Pilcher's  practice  of  washing  out 
the  middle  ear  by  means  of  a  syringe  attached  to  a  catheter  passed 
through  the  Eustachian  tube  is,  to  say  the  least  of  it,  unnecessary ; 
and  his  method  of  exploring  that  passage  and  the  tympanum,  by  in- 
troducing whalebone  sounds  and   silver  stylettes,  is  rather  heroic. 


44  WILLIAMS. 

The  author  says  :  "  The  surgeon  must  be  specially  careful  not  to  in- 
jure the  ossicula,  the  avoidance  of  which  will  require  great  caution, 
passing  as  they  do  across  the  cavity  ;  the  stylette  must,  therefore, 
just  reach  the  tympanum,  without  entering  it ;"  but  we  are  not  in- 
formed by  what  tactus  eruditus  this  is  effected.  Mr.  Pilcher's  trea- 
tise is  illustrated  in  both  the  anatomical  and  pathological  depart- 
ments ;  but  not  in  accordance  with  the  state  of  art  in  Great  Britain 
fourteen  years  ago  ;  of  which  the  relation,  size,  shape,  and  bearing 
of  the  Eustachian  tube  and  meatus  auditorius  externus,  in  Plate  IX. 
fig.  1,  is  an  example.  It  is  very  difiicult  to  have  a  faithful  drawing 
made  of  the  appearance  of  the  membrana  tympani  in  disease ;  in  fact 
the  artist  requires  to  be  well  acquainted  with  aural  pathology  before 
he  can  be  perfectly  successful ;  and  therefore  this  defect — which  has 
not  as  yet  been  remedied — is  one  of  the  causes  which  retard  the  pro- 
gress of  aural  medicine.  It  is  therefore  of  great  importance  that 
the  appearance  of  the  external  surface  of  the  membrana  tympani, 
which,  from  its  concealed  position,  very  few  persons  ever  see,  should 
be  well  .described,  both  in  a  healthy  and  diseased  state,  and  all  the 
peculiarities  of  the  former  accurately  recorded.  One,  consequently, 
regrets  that  Mr.  Pilcher  did  not  record  the  ordinary  appearances  of 
this  structure,  as  seen  with  a  stream  of  well-directed  sunlight  upon 
it,  when  describing  its  anatomical  relations  and  connexions  ;  in  one 
point  of  which  latter  I  must  differ  with  him,  and  this  point  it  is 
necessary  to  allude  to,  because  it  really  is  of  practical  importance  to 
those  commencing  the  study  of  aural  diseases,  and  having,  perhaps, 
to  observe  for  themselves,  without  the  benefit  of  clinical  instruction, 
to  know,  that  in  the  usual  erect  position  of  the  human  subject,  the 
manubrium  of  the  malleus,  which  is  the  chief  object  on  which  the  eye 
first  rests  in  examining  the  ear,  is  not  "  inclined  a  little  forwards,  but 
particularly  inwards,"  but  proceeds  downward  and  backwards.  As 
it  is  not  intended  to  discuss  the  opinions  of  authors  at  any  length  in 
the  practical  and  descriptive  portions  of  this  work,  these  observations 
will  not,  I  trust,  be  deemed  inappropriate  here. 

In  1840  Dr.  J.  Williams  published  a  "  Treatise  on  the  Ear ;  includ- 
ing its  Anatomy,  Physiology,  and  Pathology ;"  which  was  originally 
written  as  an  Inaugural  Dissertation  at  Edinburgh,  and  for  which  a 
gold  medal  was  awarded  the  author  by  the  Senatus  Academicus  of 
that  University.  It  is  a  valuable  and  unassuming  compilation,  well 
"got  up,"  and  with  good  engravings,  but  it  has  not  added  much  to 
our  stock  of  knowledge  on  the  subject,  and  is  more  valuable  as  a  book 


T.     WHARTON    JONES.  45 

of  reference  than  a  practitioner's  guide  or  student's  manual.  Cooper's 
Surgical  Dictionary,  especially  the  seventh  edition,  published  in  1848, 
also  contains  much  curious  information,  and  quotes  many  remarkable 
cases  bearing  upon  aural  surgery. 

In  the  ninth  Part  of  the  Cyclopedia  of  Practical  Surgery,  published 
in  1841,  Mr.  T.  Wharton  Jones  wrote  the  article,  "  Ear  and  Hearing, 
Diseases  of."  This  essay  was,  as  might  be  expected  from  the 
character  and  talents  of  its  author,  by  far  the  best  resume  of  the 
subject  which  had  appeared  in  British  print, — highly  learned,  and 
at  the  same  time  in  many  respects  practical.  Mr.  Jones  commences 
with  an  introduction  upon  the  analogy  which  exists  between  the  ana- 
tomy and  pathology  of  the  organs  of  sight  and  hearing,  which  we 
should  like  to  have  found  carried  on,  as  we  believe  it  might  be,  through 
the  entire  essay,  the  more  especially  as  from  the  author's  education 
and  peculiar  acquirements  it  is  probable  that  it  could  have  been  done 
with  greater  advantage  by  him  than  by  any  other  writer.  He  is  an 
advocate  for  Eustachian  catheterism  and  the  use  of  vaporous  injec- 
tions to  a  greater  extent  than  will,  I  believe,  be  found  hereafter  neces- 
sary. He  has,  moreover,  introduced  into  this  article  the  minute  de- 
tails and  daily  records  of  cases,  occupying  ten  pages,  which  is  rather 
an  unusual  proceeding  in  cyclopaedia  writings,  and  more  in  accordance 
with  the  state  of  medical  literature  thirty  years  ago  than  at  the  time 
it  was  written.  It  would  partake  more  of  the  nature  of  a  review  than 
a  literary  analysis,  were  I  to  enter  upon  a  lengthened  criticism  of 
these  cases,  but  their  perusal  will,  I  think,  convince  the  reader  of 
their  inapplicability  to  the  place  where  they  are  inserted.  One  case, 
the  first  recorded  by  the  author,  is  worthy  of  note.  A  female  com- 
plained of  deafness  accompanied  by  tinnitus,  the  consequence  of  a 
cold.  The  external  auditory  passages  were  impacted  with  hardened 
wax.  On  the  left  side  the  hearing  distance  by  a  watch  was  but  two 
inches.  Upon  the  wax  being  removed  by  syringing,  the  hearing  dis- 
tance was  increased  to  '^Mteen  feet  four  inches  !"  and  the  tinnitus 
entirely  removed.  The  membrana  tympani  is  said  to  have  been 
"  opaque,  and  slightly  yellow ;"  but  the  report  does  not  state  whether 
the  patient  could  herself  inflate  the  cavity  of  the  drum.  A  solution  of 
acetate  of  lead  was  poured  into  the  auditory  passages  two  or  three  times 
a  day.  For  some  days  the  hearing  distance  varied ;  a  catheter  was  then 
introduced,  and  the  air-douche  applied.  Upon  the  third  application 
the  air  penetrated  the  tympanum  freely,  and  the  hearing  distance  was 
then  increased  to  nineteen  feet  nine  inches ;  but  the  report  does  not 


46  YEARSLEY'S    PUBLICATIONS. 

say  wliat  it  was  previous  to  the  application  of  the  douche.  There  are 
few  persons  who  have  ever  experienced  the  stuffing  and  annoyance 
consequent  upon  "  a  cold  in  the  head,"  or  any  swelling  or  irritation  of 
the  mucous  membrane  of  the  fauces,  throat,  and  nose,  who  have  not 
experienced  sensations  and  variations  in  hearing  similar  to  those  re- 
corded in  the  case  related  in  the  Cyclopaedia  of  Surgery,  but  who 
have  generally  cured  themselves  by  blowing  the  nose,  sneezing,  or 
coughing.  Moreover,  when  wax  has  been  a  long  time  impacted  in 
the  auditory  passage,  it  often  presses  the  tympanal  membrane  inwards, 
and  the  patient  does  not  quite  recover  the  hearing,  or  get  rid  of  the 
tinnitus,  for  some  days  after  the  removal  of  the  cerumen,  or  until  a 
forced  expiration  presses  the  membrane  outwards  into  its  natural 
position. 

During  the  last  fourteen  years'  Mr.  Yearsley,  of  London,  has  pub- 
lished several  works  (and  issued  several  editions  of  each)  in  connexion 
with  diseases  of  the  ear.  The  first  of  these  was  Part  I.  of  "  Contri- 
butions to  Aural  Surgery,"  consisting  of  the  Proceedings  of  the 
meetings"  of  the  committee  for  managing  "  The  Institution  for  curing 
Diseases  of  the  Ear,"  to  which  was  added  a  Medical  Report,  and  also 
the  detailed  account  of  cases.  The  earliest  of  these  tracts  appeared 
in  1839,  and  the  third,  which  is  the  last  I  have  seen,  in  1841.  They 
abound  in  copious  extracts  from  various  authors,  and  in  particular 
from  the  then  recently  translated  work  of  Kramer.  In  these  publi- 
cations the  author  chiefly  labors  to  impress  upon  the  profession  and 
the  public  the  necessity  of  Eustachian  catheterism  in  all  diseases  of 
the  ear.  In  1842,  Mr.  Yearsley  published  "  A  Treatise  on  the  En- 
larged Tonsil  and  the  Elongated  Uvula,  in  connexion  with  Defects  of 
Voice,  Speech,  and  Hearing,"  &c.,  of  which  several  editions  have  since 
appeared.  The  author  recommends  excision  of  the  tonsils  for  the 
cure  of  deafness,  and  we  believe  a  great  number  of  persons  have  since 
submitted  to  the  operation  ;  but  with  what  degree  of  success  the  pro- 
fession in  London  are  the  best  judges.  Every  practical  physician  and 
surgeon  must  be  well  aware  that  enlarged  tonsils  do  not  of  necessity 
produce  deafness ;  I  shall,  however,  leave  the  further  discussion  of 
that  subject  to  the  work  of  Mr.  Harvey,  to  be  noticed  presently.  In 
1847  there  appeared  by  the  same  author,  "  Deafness  practically  illus- 
trated, being  an  Exposition  of  Original  Views  as  to  the  Causes  and 
Treatment  of  Diseases  of  the  Ear."  These  original  views  consist  of 
a  reprint,  with  scarcely  an  alteration,  of  the  three  original  tracts 
originally  published,  from  1838  to  1841,  and  a  large  portion  of  the 


YEARSLEY,     DUFTON,     AND     HARVEY.  47 

book  upon  the  Throat,  just  referred  to,  to  wMch  were  added  chapters 
upon  "  Stomach  Deafness;"  the  Statistics  of  Deafness;  on  the  best 
means  of  compensating  for  Incurable  Deafness  ;  and  on  Ear  Trum- 
pets. The  author's  description  of  stomach  deafness  is  as  follows : — 
"  The  so-called  nervous  deafness,  hitherto  a  stumbling-block  to  con- 
temporary writers,  is  nothing  else  than  an  injurious  influence  exerted 
on  the  ear  by  dyspeptic  ailments,  though  commonly  pronounced  a 
disease  depending  primarily  on  the  auditory  nerve  itself."  And 
again: — "  The  first  description  of  deafness  from  digestive  disorder  is 
that  in  which  the  disease  is  strictly  confined  to  the  stomach,  no  per- 
ceptible change  having  occurred  in  the  organ  of  hearing,  except  func- 
tional torpor  of  the  auditory  nerve.  This  is  best  seen  in  acute  indi- 
gestion." Obstruction  of  the  biliary  secretion,  accumulation  of  mor- 
bid bile  in  the  gall  ducts,  and  chronic  dyspepsia,  are  the  other  abdo- 
minspl  derangements  supposed  by  the  author  to  produce  deafness, 
which  he  believes  to  be  caused  by  an  extension  of  a  sub-inflammatory 
condition  of  the  mucous  membrane  into  the  throat,  and'  thence  into 
the  cavity  of  the  ear,  and  even  to  the  external  meatus !  To  Mr. 
Yearsley,  however,  is  due  the  credit  of  having  first  drawn  the  attention 
of  the  profession  to  the  very  valuable  remedy  of  introducing  a  portion 
of  moist  cotton  into  the  external  meatus  in  cases  of  deafness  arising 
from  perforation  of  the  tympanal  membrane.  The  original  communi- 
cation upon  this  subject  was  published  in  "  The  Lancet"  for  July, 
and  was  afterwards  reprinted  as  a  tract  upon  "  A  New  Mode  of  treat- 
ing Deafness  when  attended  by  a  partial  or  entire  Loss  of  the  Mem- 
brana  Tympani,  associated  or  not  with  Discharge  from  the  Ear." 
This  question  will  be  again  considered  in  the  practical  portion  of  this 
work  devoted  to  Otorrhoea, 

In  1844  Mr.  W.  Dufton,  of  Birmingham,  published  a  little  work,  en- 
titled "  The  Nature  and  Treatment  of  Deafness  and  Diseases  of  the 
Ear,  and  of  the  Treatment  of  the  Deaf  and  Dumb."  And  in  184T 
Dr.  J.  W.  Moses,  of  St.  Asaph,  wrote  a  short  "  Treatise  on  the  Hu- 
man Ear,  with  new  Views  of  the  Physiology  of  the  Tympanum." 

Mr.  W.  Harvey,  of  London,  has  written  some  papers  on  Aural  Sur- 
gery in  the  periodicals,  and  published  a  Chart  of  Diseases  of  the  Ear, 
of  which  he  issued,  in  connexion  with  Mr.  Thomas  Buchanan, 
of  Hull, — to  whose  works  I  have  already  alluded  at  page  39, — a 
second  edition  in  1848,  entitled  "  A  New  and  Improved  Synoptical 
Table  of  the  Diseases  of  the  Human  Ear,  with  their  Symptoms,  Causes, 
and  Treatment."     Simplicity  of  nomenclature  characterizes  most  mo- 


48  HARVEY. 

dern  medical  ■writings,  at  least  in  Great  Britain,  and  to  this  end  the 
labors  of  Mr.  Farr,  in  his  various  publications  upon  Vital  Statistics, 
have  tended  in  no  small  degree.  One  can  therefore  scarcely  appre- 
ciate the  advantage  derivable  from  any  classification  abounding  in 
terms  like  the  following : — akoluthige,  dermatine,  anachrosis,  ptosees, 
kerinaditis,  sunakolouthesis,  derringitis,  apoplanesis,  laburinthitis, 
steresis,  skleragosis,  &c.,  &c.  In  1850  Mr.  Harvey  published  a  book 
"  On  Excision  of  the  Enlarged  Tonsil,  and  its  Consequences  in  cases 
of  Deafness,  with  Remarks  on  Diseases  of  the  Throat."  In  this  most 
useful  work  the  author  has  fairly  established  the  fact  that  removal  of 
the  tonsils  does  not  cure  deafness,  and  that,  independent  of  any  risk 
in  the  operation  itself,  the  excision  of  these  bodies  is  often  attended 
with  subsequent  unpleasant  results  to  the  patients.  Every  author 
who  writes  on  any  subject  connected  with  diseases  of  the  ear  thinks 
it  necessary  to  conclude  his  work  with  a  chapter  on  deaf-dumbness, 
although  very  few  modern  writers  have  added  anything  to  our  stock 
of  knowledge  as  regards  the  statistics,  medical  treatment,  moral  ma- 
nagement, or  pathology  of  that  affection,  because  very  few  practitioners 
have  any  experience  of  such  matters.  The  following  paragraph  upon 
this  subject,  from  Mr.  Harvey's  work,  is  an  example  : — "  A  deaf-mute 
can  learn  to  read  and  speak  perfectly,  without  hearing  a  single  tone ; 
so  that  the  only  true  test  of  a  deaf-mute  is  his  being  able  to  converse 
with  a  stranger  as  well  without  the  aid  of  his  eyes  as  any  person  who 
hears  well  is  daily  in  the  habit  of  doing," — page  104.  Now  in  the 
English  and  American  schools,  and  most  of  those  on  the  Continent, 
all  attempts  to  make  the  deaf  and  dumb  articulate  have  of  late  years 
been  relinquished ;  and  how  the  deaf-mute  is  able  to  converse  with  a 
stranger  without  the  aid  of  his  eyes,  one  is  at  a  loss  to  discover. 
Mr.  Harvey  promises  to  translate  and  annotate  the  work  of  Lincke 
referred  to  at  page  42,  and  also  to  afford  us  a  book  on  certain  rheu- 
matic diseases  of  the  ear. 

Among  the  writings  bearing  on  this  subject  may  be  mentioned  the 
interesting  work  of  the  Rev.  Dr.  Kitto  on  "  The  Lost  Senses — Series 
I.  Deafness,"  published  in  1845,  in  which  the  feelings,  sensations,  and 
impressions  of  the  author,  himself  the  subject,  as  he  states  of  "  the 
most  intense  deafness  to  which  any  living  creature  can  be  subjected," 
are  graphically  and  feelingly  described. 

The  labors  and  investigations  of  Mr.  Toynbee  have  effected  more 
for  aural  pathology  than  those  of  all  his  predecessors  either  in  Eng- 
land or  on  the  Continent.     He  commenced  at  the  right  end,  and  has 


toynbee's  reseaeches.  49 

travelled  in  the  proper  direction.  He  lias  brought  to  bear  upon  the 
subject  the  true  principles  of  science,  and  with  the  assistance  of  the 
microscope, — the  aid  of  every  modern  artistic  appliance  to  assist 
him, — accustomed  to  habits  of  minute  dissection,  patient  research, 
and  careful  observation, — he  has  accumulated  a  mass  of  facts  upon 
the  morbid  anatomy  of  the  organs  of  hearing  that  must  lay  the  foun- 
dation for  a  more  rational  mode  of  treating  the  diseases  of  those  parts 
than  has  heretofore  been  resorted  to.  Mr.  Toynbee  has  already  re- 
corded the  results  of  the  dissection  of  the  ears  of  about  750  persons 
sent  to  him  for  examination,  but  of  which  number  not  more  than  sixty 
or  seventy  were  from  persons  the  history  of  whose  deafness  was 
known. 

Mr.  Toynbee  has  labored  extensively,  and  with  effect,  to  discover 
and  describe  the  post  mortem  appearances  which  disease  has  pro- 
duced in  the  organ  of  hearing ;  and  I  trust  he  will  long  continue  to 
prosecute,  with  the  same  avidity,  the  same  honesty  of  purpose,  and 
an  equal  amount  of  critical  acumen,  his  valuable  researches.  Morbid 
anatomy,  however,  is  one  thing — pathology  another.  The  dead  sub- 
ject upon  the  dissecting-table  teaches  the  student  not  disease,  but  the 
results  of  disease.  It  avails  little  that  the  hospital  pupil  should  have 
pointed  out  to  him,  in  the  dead-room,  the  violence  which  sudden  acci- 
dents may  have  caused,  or  the  ravages  which  slow  disease  has  pro- 
duced in  the  various  organs  or  textures  of  the  body ;  it  matters  not 
to  what  extent  the  microscope  may  exhibit  the  wide-spread  lesion,  or 
chemical  tests  disclose  morbid  products,  unless  the  cases  have  been 
observed  during  life,  and  the  progress  of  disease  previously  noted  at 
the  bedside.  Therefore  it  is  that  the  School  of  Vienna, — where  a 
dozen  bodies  from  different  parts  of  the  Great  Hospital,  but  the  his- 
tories of  which  are  unknown,  are  sometimes  cut  up,  and  their  post 
mortem  appearances  displayed  in  the  lecture-room  on  a  morning, — 
may,  under  the  able  teaching  of  Rokitansky,  Engel,  and  others, 
teach  morbid  anatomy  (pathology  so  called),  but  does  not  produce 
many  practical  physicians. 

Mr.  Toynbee's  researches  prove  the  position  which  I  long  ago 
advanced,  and  which  from  year  to  year  I  have  been  in  the  habit,  not 
only  of  teaching  theoretically,  but  practically  demonstrating  in  my 
clinical  lectures, — that  the  great  majority  of  diseases  of  the  ear  pro- 
ducing deafness  have  their  origin  in  inflammation  of  one  kind  or  an- 
other. Every  day's  experience  confirms  me  in  this  opinion ;  and  the 
cases  which  I  now  publish  will,  I  think,  corroborate  that  view  of  the 


50  THE    GLYCEKINE    CURE. 

subject.  Mr.  Toynbee  has  not  yet  published  any  separate  work  upon 
the  ear,  but  has  contributed  his  observations  on  the  Anatomy,  Patho- 
logy, and  Treatment  of  the  Organs  of  Hearing  to  the  different  socie- 
ties, and  also  to  the  periodicals,  of  London.  Among  the  latter  may 
be  mentioned  chiefly,  the  Philosophical  and  Medico-Chirurgical  Trans- 
actions, from  1843  until  the  present  date.  He  has  also  written  several 
valuable  papers  in  the  Medical  Times,  Lancet,  Provincial  Journal,  and 
Edinburgh  Medical  Journal. 

Subsequent  to  Mr.  Yearsley's  recommendation,  a  fluid  called  gly- 
cerine was  recommended,  on  account  of  its  inevaporability, — a  pro- 
perty which  it  undoubtedly  possesses  more  than  most  other  liquids, — 
as  the  only  proper  substance  with  which  to  moisten  the  wool  or  cotton 
introduced  into  the  meatus  in  cases  of  perforate  membrana  tympani ; 
and  from  being  employed  with  effect  in  one  set  of  cases,  its  virtues 
were  vaunted  as  a  cure  for  all,  and  during  the  last  few  years  we  hear 
this  medicine  extolled  in  the  public  newspapers,  as  well  as  the  medical 
periodicals,  as  a  panacea  for  deafness  of  all  kinds,  and  arising  from 
all  causes.  The  virtues  of  glycerine  were  first  made  known  to  the 
profession  through  Mr.  T.  Wakley,  who  published  an  account  of  it 
in  the  Lancet  in  1849.  Since  then  glycerine  has  had  "  a  run,"  par- 
ticularly among  the  members  of  the  profession  not  specially  engaged 
in  the  treatment  of  aural  diseases ;  and  we  may,  therefore,  well  ima- 
gine in  what  a  variety  of  cases,  arising  from  the  most  opposite  causes, 
and  presenting  a  totally  different  set  of  symptoms,  this  remedy  has 
been  applied.  Cases  of  nervous  deafness  of  long  standing,  thicken- 
ing and  opacity  of  the  membrana  tympani,  inflammation  and  mucous 
engorgement  of  the  cavity  of  the  tympanum,  thickening  of  the  cuti- 
cular  lining  of  the  meatus  resulting  from  otorrhoea,  the  various  in- 
flammatory affections  of  the  ear,  as  well  as  simple  impaction  of  the 
meatus  with  cerumen,  are  constantly  forwarded  to  me  by  practitioners 
with  the  following  note  : — "  We  have  applied  the  glycerine,  as  lately 
recommended  for  the  cure  of  deafness,  for  some  weeks  past ;  but  the 
patient  not  having  experienced  relief,  we  wish  to  have  your  opinion," 
&c.  When  the  case  does  not  turn  out  favorably,  it  is  said  by  its 
supporters  that  the  remedial  agent  is  not  pure  ;  and  when  its  purity 
has  been  tested  and  proved,  then  it  turns  out  that  the  remedy  was 
inapplicable  to  that  particular  case.  Like  all  other  remedies  proposed 
for  deafness,  it  has  been  misapplied,  and  even  the  original  intention 
of  its  inventor  lost  sight  of.  The  cases  to  which  it  is  said  to  be  most 
applicable  are  those  of  defective  cerumen,  dryness  of  the  auditory 


THE     GLYCEEIXE     CURE.  51 

passage,  thickening  of  the  membrana  tympani,  and  that  peculiar  con- 
dition of  the  epithelial  lining  of  the  external  conduit  which  results 
from  previous  otorrhoea.  Deficiency  of  cerumen  is  but  a  symptom 
contingent  upon  other  diseases ;  it  is  not  of  itself  a  disease  of  the 
ear  nor  a  cause  of  deafness ;  and  no  better  proof  of  this  can  be 
oflFered  than  that  instanced  by  a  case  of  defective  hearing  caused  by 
accumulation  of  hardened  wax.  The  patient  is  totally  deaf,  and 
labors  under  tinnitus  aurium  and  other  symptoms  consequent  upon 
such  mechanical  obstructions,  which  are  well  known  to  every  practi- 
tioner. The  application  of  a  jet  of  warm  water,  properly  directed, 
removes  the  hardened  wax,  when  the  hearing  is  instantaneously 
restored,  nay,  often  considerably  exalted.  In  a  few  hours  the 
meatus  becomes  perfectly  dry.  Why  then  is  it  that  the  hearing 
remains  perfect,  although  the  cerumen  has  been  completely  washed 
away  ?  Again,  as  to  dryness  and  paleness  of  the  meatus,  it  should 
be  remembered  that  such  is,  with  the  exception  of  the  part  coated  by 
cerumen,  its  natural  condition.  As  regards  thickening  and  opacity 
of  the  tympanal  membrane,  if  glycerine  can  remove  such,  either  by 
maceration,  any  caustic  property  which  it  may  possess,  or  by  inducing 
absorption,  then  indeed  will  it  be  found  a  great  boon.  In  cases  of 
thickening  of  the  lining  membrane  of  the  meatus,  and  a  dry,  scaly 
condition  of  the  epithelium,  upon  the  drying  up  of  a  muco-purulent 
discharge,  it  is  of  importance  to  restore  these  parts  to  a  healthy  con- 
dition by  remedial  agents,  of  which  glycerine  is  not  the  best  nor  the 
only  one.  There  are,  however,  cases  in  which  benefit  will  be  derived 
from  preserving  the  meatus  and  external  layer  of  the  membrana  tym- 
pani  moist.  The  eifect  of  such  moisture  is  well  known,  not  only  to 
aui^al  surgeons,  but  to  patients  themselves,  who  are  in  the  habit  of 
applying  a  little  oil  or  even  water  upon  the  point  of  the  finger  to  the 
external  meatus  whenever  they  find  their  hearing  particularly  defec- 
tive ;  and  in  such  cases  this  remedy,  from  its  remarkable  property  of 
remaining  fluid,  when  most  other  liquids  evaporate,  will  be  foimd 
useful.     Such  cases,  however,  are  comparatively  rare. 

The  substance  denominated  glycerine  was  discovered  by  Scheele, 
and  afterwards  investigated  by  Chevreul.  It  is  an  almost  inodorous, 
syrupy  fluid,  which  gives  a  peculiar  smoothness  to  the  part  on  which 
it  is  rubbed,  and  is  obtained  in  the  making  of  litharge  plaster,  by 
washing  that  substance,  and  passing  sulphuretted  hydrogen  gas 
through  the  washings  to  remove  the  lead, — afterwards  filtering  and 
evaporating.     It  is  soluble  in  water  and  alcohol ;  does  not  dry  or 


52  WAKLEY    ON    GLYCERINE. 

evaporate  at  the  ordinary  temperature,  but  if  boiled,  it  partly  distils 
and  partly  decomposes,  acroleine  being  among  its  products, — and  it 
is  not  liable  to  ferment.  It  is  found  in  combination  with  most  oils, 
except  that  obtained  from  the  liver  of  the  cod,  now  in  such  extensive 
use,  which  Winder  has  ascertained  does  not  contain  it.  Time,  and 
the  experience  of  the  profession,  which  test  all  such  remedies,  no 
matter  how  vaunted  or  how  popular,  will,  no  doubt,  develope  the  the- 
rapeutical eflfects  of  this  substance  in  diseases  of  the  ear,  if  such  it 
possesses,  beyond  those  which  I  have  already  stated.  Its  powers 
are  already  beginning  to  be  questioned  ; — a  book  has,  however,  been 
written  on  the  subject, — the  last  in  connexion  with  diseases  of  the 
ear  which  has  appeared  in  Great  Britain, — and  in  accordance  with 
the  principles  of  this  chapter  it  must  be  referred  to. 

In  1851,  there  appeared  "  Clinical  Reports  on  the  use  of  Glyce- 
rine in  the  treatment  of  Certain  Forms  of  Deafness,  by  T.  Wakley, 
F.  R.  C.  S.  Edited  by  W.  Tindal  Robertson."  Any  proposition  to 
relieve  so  serious  and  so  widely-spread  an  infirmity  as  deafness, 
emanating  from  a  legalized  practitioner,  should  be  hailed  by  the  pro- 
fession as  a  benefit  conferred  upon  science  and  humanity  ;  but  at  the 
same  time  it  behooves  the  propounders  of  such  cures  to  show  that 
their  cases  are  well  worthy  of  credence,  and  that  their  descriptions 
of  disease,  details  of  symptoms,  diagnosis,  and  prognosis,  are  in  ac- 
cordance with  the  present  state  of  medical  science  bearing  upon  such 
afi"ections.  Now,  I  do  not  think  this  work  is  in  that  position.  For 
the  application  of  glycerine  the  author  recommends  an  instrument  re- 
sembling a  porte-crayon,  for  holding  a  piece  of  cotton  saturated  with 
the  new  remedy.  The  external  meatus  being  washed  out  with  tepid 
water,  and  thoroughly  dried,  which  appears  to  be  a  necessary  pre- 
liminary, we  are  gravely  informed  that  the  cotton  "  should  be  so 
fixed  that  in  moving  the  instrument  to  and  fro  in  the  external  meatus, 
the  free  passage  of  air  should  be  provided  for,  otherwise  an  imperfo- 
rate tympanum  might  he  ruptured."  !  !  The  book  contains  the  re- 
cord of  twenty-eight  cases,  in  the  majority  of  which  the  streets,  but 
not  the  numbers,  in  which  the  patients  lived,  are  given.  The  hearing 
distance  before  the  application  of  the  remedy  is  not  stated,  although 
the  author  has,  he  states,  invented  an  instrument,  which  he  styles  a 
Sonometer,  for  the  purpose  of  measuring  the  hearing  distance,  and 
which,  he  says,  "  has  proved  of  the  greatest  value  in  practice,"  and 
"  has  done  service  to  the  profession."  But  what  that  value,  and 
what  that  service  is,  beyond  what  may  be  acquired  by  an  ordinary 


GLYCEKINE     IN     DEAF-DUMBNESS.  53 

loud-ticking  watch,  is  not  recorded.^  In  reading  over  these  cases, 
when  we  find  such  statements  as  the  following,  we  are  inclined  to 
think  that  their  reporter — we  suppose  some  pupil  of  Mr.  Wakley's 
— was  not  verj  conversant  with  either  the  normal  or  pathological 
appearances  of  the  human  ear  : — "  The  tympanum  of  each  ear  was 
sound." — "  The  tympanum  of  each  ear  was  perfect." — "  Care  having 
been  taken  to  apply  it  to  the  tympanum."  We  suppose  the  reporter 
alluded  to  the  membrana  tympani.  Again  we  read :  "  When  the 
ears  are  under  the  influence  of  glycerine." — "  The  meatus  of  each 
ear  is  exceedingly  hard." — "  Of  a  very  pale  color." — "  The  aural 
passage  and  tympanum  [j^ucere  middle  ear]  exhibited  a  white,  polished 
appearance,"  &c.  Among  the  cases  related  is  that  of  a  boy,  deaf 
and  dimib,  in  which  the  author  says  : — "  The  ears  are  very  small." 
We  then  hear  that  the  "  ears  were  well  saturated  with  glycerine," 
and  the  hearing  distance  tested,  when,  marvellous  to  relate,  the  boy 
seemed  "  to  signify  with  his  fingers  the  number  of  times  he  was 
called  by  his  father."  "  It  is  evident,"  says  the  author,  in  conclud- 
ing the  report  of  this  case,  "  that  he  received  a  certain  amount  of 
benefit  from  the  glycerine."  Here  now  is  a  fair  case  : — E.  M.,  Dean 
Street,  London,  a  deaf-mute,  who  is  said  to  have  derived  benefit  from 
this  remedy.  Let  the  boy  be  produced  to  the  profession,  and  to 
the  instructors  of  the  deaf  and  dumb,  and  let  them  decide  upon  the 
amount  of  benefit  derived  from  this  or  any  other  remedial  agent  in 
cm'ing  a  case  of  true  muteism.  These  cases,  however,  in  which  even 
"  a  certain  amount  of  benefit"  is  said  to  have  been  derived  from 
treatment  of  any  kind  by  an  unhappy  deaf-mute,  have  their  efi"ect 
upon  the  public  mind,  as  was  instanced  some  years  ago  in  the  Turn- 
bull  cures  related  in  Chambers's  Jom-nal,  to  be  referred  to  presently. 
In  a  second  section  of  this  book,  consisting  of  a  clinical  lecture  on 
the  use  of  glycerine,  illustrated  by  eleven  cases,  in  which  the  remedy 
is  most  advisable,  we  find  that  four  were  instances  of  simple  impac- 
tion of  wax,  which  might  have  been  removed  in  a  few  minutes  by 
some  warm  water  and  a  syringe.  In  the  first  portion  of  the  work, 
dry  cotton  is  the  substance  recommended  for  the  application  of  the 
glycerine  ;  in  the  latter  section,  however,  at  p.  64,  sheep's  wool  is 
that  deemed  most  advisable  by  the  author.  I  have  already  alluded 
at  p.  19  of  this  chapter  to  the  old  Irish  remedy,  which  partakes  more 
of  the  nature  of  a  superstition  than  a  therapeutic  agent,  of  a  cure 

'  I  saw  a  similar  instrument  used  by  Dr.  Schmalz  in  Dresden  in  1840.     He  claimed 
the  invention  of  it,  and  has  described  it  in  his  various  writings. 


54  TURNBULL. 

for  deafness,  in  a  bit  of  wool,  taken  at  a  particular  time,  and  under 
particular  circumstances,  from  the  left  fore-leg  of  a  six-year  old  black 
ram.  In  the  metropolis  of  the  world,  during  the  middle  of  the  nine- 
teenth century,  with  science,  philosophy,  and  common  sense  influ- 
encing the  actions  of  mankind  to  the  extent  which  at  present  prevails, 
one  did  not  expect  to  find  the  surgeon  of  a  London  hospital  recom- 
mending as  a  portion  of  the  new  cure  for  deafness,  "  the  finest  curled 
wool  on  the  sheep's  head,  carefully  cut  Avith  scissors,  and  washed  in 
hot  water,"  and  adding,  "  the  best  wool  is  that  procured  from  a  small 
German  sheep  ;"  age  unspecified. 

I  have  dwelt  thus  long  upon  the  present  popular  cure  for  deafness, 
and  endeavored  to  expose  its  fallacy,  in  the  hope  that  the  eyes  of  the 
profession  may  be  opened  to  the  inefficacy  of  such  modes  of  treatment, 
and  that  our  continental  neighbors  may  not  have  an  opportunity 
again  of  writing  such  critical  reviews  of  British  authors  as  those 
which  formed  an  introduction  to  Dr.  Kramer's  book. 

Well-educated  surgeons  and  honest  men  have  at  last  come  forward 
to  rescue, this  branch  of  the  healing  art  from  the  hands  of  quacks  and 
charlatans ;  and  the  names  of  those  respectable  gentlemen  who  at 
present  practise  aural  surgery  in  Great  Britain  are  a  sufficient  gua- 
rantee that  the  empiric  and  the  nostrum-monger  will  be  soon  driven 
-from  the  field.  Yet  that  some  of  those  latter  still  drive  a  thriving 
trade  may  be  learned  from  the  puffs  and  praises  bestowed  upon  them 
in  the  literary  periodicals  of  the  day.  In  one  of  these,  which,  from 
our  own  knowledge  of  the  honor  and  integrity  of  its  editors,  as  well 
as  its  hitherto  stern  and  uncompromising  stand  against  quackery  of 
every  description,  and  its  high  reputation  for  honesty  of  purpose  and 
substantial  literary  merit,  we  really  expected  better  things,  it  was  some 
time  ago  not  only  asserted,  but  endeavored  to  be  proved,  that  by  drop- 
ping "an  alkaloid"  into  the  external  meatus,  or  rubbing  the  surface 
of  the  membrana  tympani  with  it,  persons  born  deaf  and  dumb  have 
been  almost  instantaneously  cured  !  nay,  not  only  is  hearing  restored  on 
the  moment,  but  the  miracle  (for  miracle  it  certainly  is,  if  true)  ex- 
tends to  the  organs  of  speech  also,  as  in  one  case,  and  that  too  given 
on  the  faith  of  a  medical  man,  and  conveyed  in  a  letter  to  the  operator, 
he  says,  that  "after  repeated  examinations  of  many  of  the  objects 
under  your  care,  previously  to  anything  being  done,  I  satisfied  my- 
self that  they  were  both  deaf  and  dumb.  I  have  witnessed  the  ap- 
plication of  your  remedy  to  the  ears,  and  bear  testimony  to  them 
having  in  my  presence  obtained  the  sense  of  hearing."     But — miracle 


TURNBULL  AND  HIS  REVIEWERS.  55 

upon  miracle — the  faculty  of  speech  to  one  who  had  never  heard  the 
sweet  sounds  of  a  human  voice,  follows  almost  as  a  matter  of  course  ; 
for,  adds  the  narrator,  "  and  by  my  own  tuition,  in  a  feiv  minutes 
afterivards  acquired  the  power  of  speech!''  I  wonder  was  it  broad 
Scotch  they  spoke  ! 

The  history  of  this  affair  is  as  follows : — In  1837  there  appeared 
in  London  "  A  Treatise  on  Painful  and  Nervous  Affections,  and  on  a 
new  mode  of  Treatment  for  Diseases  of  the  Eye  and  Ear,  by  A. 
Turnbull,  M.D."  The  portion  devoted  to  the  consideration  of  affec- 
tions of  the  latter  organ  is  comprised  in  six  pages,  and  the  treatment 
consisted  of  the  application  of  the  alkaloid  veratria  to  the  external 
meatus  and  the  parts  joining  the  aui'icle.  "  Feeling  satisfied,"  says  the 
author,  "  that  I  had  in  my  possession  means  decidedly  effective  in  pro- 
moting absorption  through  the  medium  of  the  nerves,  and  knowing 
that  deafness  often  arose  from  the  Eustachian  tube  being  obstructed 
by  enlarged  tonsil  glands,  I  applied  veratria  externally  over  these 
glands,  and  found  it  frequently  succeed  in  removing  their  enlargement 
and  restoring  the  hearing."  The  "  electro-stimulation,"  as  the  author 
terms  it,  having  been  found  so  efficacious  in  removing  deafness,  such 
as  has  been  described  in  the  foregoing  quotation,  he  was  induced  to 
extend  its  benefits  to  the  deaf  and  dumb,  and  shortly  afterwards  it  was 
announced  that  Dr.  Turnbull  had  cured  several  deaf-mutes  ;  and  ad- 
vertisements appeared  in  the  newspapers  for  persons  to  instruct  those 
patients  cured  by  such  means.  The  possessor  of  this  valuable  dis- 
covery next  proceeded  to  Scotland,  to  operate  upon  the  deaf  and  dumb 
portion  of  the  inhabitants  of  that  country,  but  his  cures  were  ques- 
tioned, and  his  statements  rather  severely  criticised,  in  that  valuable 
pubhcation,  Chambers's  Journal,  for  28th  September,  1839.  By  some 
means,  however,  he  afterwards  proved  his  case  to  the  satisfaction  of 
the  editors,  and  then,  in  their  publication  for  8th  January,  1842,  No. 
519,  they  acknowledged,  in  an  article  headed  "  Cures  for  Deafness," 
the  injustice  of  their  previous  attack,  and  were  equally  loud  in  praise 
of  the  cures  said  to  have  been  achieved.  Several  of  these  cures  were 
said  to  have  been  effected  upon  children  either  in  the  Deaf  and  Dumb 
Institutions  of  Scotland,  or  known  to  some  of  the  principals  in  these 
establishments  ;  and  consequently  the  late  Mr.  Robert  Kinniburgh, 
a  gentleman  of  great  truth  and  vast  experience  in  the  management 
of  the  deaf  and  dumb,  addressed  a  letter  to  the  editors,  proving  dis- 
tinctly in  each  individual  case  related  that  no  ciu-e  was  effected.    This 


56       '  CHAMBERS'S    JOURNAL. 

letter,  of  which  I  possess  a  copy,  was  published  upon  the  28th  Feb- 
ruary, 1842,  but  it  was  only  privately  circulated. 

It  is  always  a  matter  of  difficulty  to  argue  on  a  medical  subject  with 
a  non-professional  person,  for  it  is  quite  impossible  for  a  man  unin- 
structed  in  anatomy,  physiology,  medicine,  and  surgery,  to  be  con- 
vinced of  his  error, — to  form  an  opinion  of  the  merits  of  a  cure,  or  the 
causes  of  a  failure.  Such  discussions  with  non-medical  persons  should 
be  avoided  as  much  as  possible,  they  tend  to  no  good,  and  were  it  not 
our  conviction  that  Mr.  Chambers,  for  whom  we  entertain  the  highest 
respect,  had  been  made  the  dupe  of  Dr.  Turnbull,  we  would  not  thus 
have  alluded  to  the  subject  here.  How  few  students,  after  two,  or 
even  three  years'  study  in  the  preparatory  or  elementary  courses,  would 
be  capable  of  estimating  the  value  of  any  medical  production  put  into 
their  hands !  and  yet,  "  in  order  to  ascertain  in  what  respects  Dr. 
Turnbull's  practice  differed  from  that  which  is  general  in  the  profes- 
sion," we  are  gravely  informed  by  the  editors  of  the  Edinburgh 
Journal,  that  they  "  studied  the  most  recent  and  approved  works  on 
aural  surgery."  Had  the  writer  known  anything  of  the  structure  of 
the  parts  he  attempted  to  describe,  he  would  have  been  better  informed 
than  to  publish  an  account  of  an  analogy  between  the  ceruminous 
glands  in  the  external  meatus,  and  the  mammary  gland  in  the  female  ; 
for  in  the  article  to  which  I  allude  he  says  :  "  Finding  cured  persons 
relapse  in  consequence  of  the  defect  of  wax,  Dr.  Turnbull  was  prompted 
to  use  his  ingenuity  in  endeavoring  to  discover  a  means  of  sustain- 
ing that  secretion.  He  reflected  that  the  application  of  the  mouth  of 
the  child  to  its  mother's  breast,  by  removing  the  pressure  of  the  at- 
mosphere, causes  the  milk  immediately  to  flow,  and  he  conceived  that 
a  similar  result  might  follow  with  respect  to  the  wax  of  the  ears,  if 
he  could  by  any  means  remove  the  pressure  of  the  atmosphere  from 
the  external  parts.  For  this  purpose,  he  at  first  used  a  syringe  with 
an  India-rubber  mouth  exactly  fitted  to  the  aperture  of  the  ear,"  &c. 
Now  the  veriest  tyro  in  medicine  knows  that  it  does  not  depend  on 
any  atmospheric  pressure,  but  is  owing  to  a  morbid  action  in  the  fol- 
licles themselves  that  the  ear  wax  is  not  secreted.  But  yet  we  read — 
"  the  plan  was  successful ;"  and  the  reason  assigned  is,  because  "  the 
\>\oodi.-v essels  resumed  a  free  circulation,  and  the  flow  of  Avax  recom- 
menced." 

Again,  we  learn  that  "  clearing  of  the  Eustachian  tube,  for  which 
no  means  formerly  existed  but  the  application  of  medicine  to  the 
bowels,  or  the  dangerous  use  of  a  catheter,  was  effected  by  Dr.  Turn- 


IS     THE     DEAF-MUTE     CURABLE?  57 

bull  by  the  same  simple  means."  Well  might  the  friends  and  ad- 
mirers of  the  Doctor  employ  the  term  dangerous,  for  the  only  record 
of  any  accident  or  ill-effect  having  arisen  from  the  employment  of  this 
exceedingly  simple  and  harmless  operation  occurred  to  Dr.  Turnbull 
himself,  two  of  whose  patients,  in  the  year  1839,  fell  victims  to  the 
operation  of  catheterism  of  the  Eustachian  tube,  and  on  both  of  whom 
coroner's  inquests  were  held.  One  of  these,  it  appeared  in  evidence, 
was,  almost  immediately  after  the  operation,  attacked  with  emphy- 
sema of  the  throat  and  inflammation  of  the  brain,  of  which  he  died  in 
a  week ;  and  the  other,  a  lad  named  Joseph  Hall,  aged  18,  and  in 
perfect  health,  "  fell  back  in  the  chair  apparently  lifeless,  and  never 
spoke  afterwards." — (Lancet,  July  6,  1839.)  In  the  first  of  these 
cases  it  appears  most  likely  that  the  emphysema  was  caused  by  the 
instrument  rupturing  and  tearing  the  mucous  membrane  ;  and  in  the 
second,  in  all  probability,  the  death  was  caused  by  the  shock  or  con- 
cussion given  to  the  base  of  the  skull  by  the  volume  of  compressed 
air, — for  where  the  mouth  of  the  catheter  was  we  know  not.  After  this 
it  seems  the  Doctor  changed  his  hand,  and  finding  that  it  was  rather 
a  "  dangerous"  experiment  to  "  blow  up"  his  patients,  he  determined 
to  suck  them  as  much  as  possible ;  and,  in  order  to  effect  this,  Mr. 
Chambers  informs  us,  that  by  means  of  an  air-pump,  in  connexion 
with  a  small  glass-tube,  "  introduced  into  the  mouth  of  the  patient, 
and  applied  to  the  orifice  of  the  Eustachian  passage,"  and  conse- 
quently behind  and  above  the  soft  palate  !  communication  is  opened 
between  the  previously  rarified  air  in  the  receiver  and  the  orifice,  from 
which  a  discharge  of  mucus  is  soon  made  into  the  tube,  which  is  then 
withdrawn. 

With  one  word  more  let  us  dismiss  this  subject  of  Dr.  Turnbull 
and  his  reviewers ; — a  word  worthy  of  consideration  to  those  who 
may  be  induced  by  articles  such  as  that  to  which  I  have  alluded  to 
submit  their  deaf-mute  friends  or  relatives  to  useless  pain  and  profit- 
less experiment ;  and  many  an  anxious  parent — some  from  this  country 
— upon  the  faith  of  the  report  then  propagated,  and  relying  on  the 
truth  of  these  cures,  visited  the  inventor  of  the  alkaloid,  and  several 
spent  considerable  sums  of  money  in  the  vain  hope  of  even  once  hear- 
ing their  children  articulate.  That  word  is  this — and  it  is  the  more 
suitable  on  account  of  the  sanctimonious  air  assumed  in  the  applica- 
tion of  the  means  employed, — Were  the  miraculous  cures  of  the 
Saviour,  who  sighed  over  the  case  of  the  deaf-mute,  performed  on 
cases  or  in  diseases  that  art,  either  then  or  now,  could  have  reme- 


58  IKISH    WKITERS. 

died  ? — could  remedial  agents,  or  man's  interference,  have  raised  the 
dead — thrown  instantaneously  the  vigor  of  youth,  and  the  health  and 
strength  of  manhood,  into  the  limbs  of  the  cripple — given  power  to 
the  paralytic — steadiness  to  the  palsied — and  calmness  to  the  pos- 
sessed ;  or  have  cooled  the  fevered — given,  by  a  word,  sight  to  the 
blind,  speech  to  the  dumb,  and  hearing  to  the  deaf? — If,  without  the 
special  interference  of  Providence,  these  individuals  could  have  been 
cured,  then  their  cases  were  not  miracles ;  but  if  without  the  pale  of 
art,  or  beyond  the  powder  of  human  means,  then  were  they  miracles, 
and  cannot  now  be  performed  but  by  similar  means.  That,  however, 
the  age  of  miracles  was  at  hand,  Mr.  Chambers  appeared  to  have 
some  idea,  for,  no  doubt,  aware  of  the  instantaneous  restoration  of 
speech  and  hearing  to  the  deaf-mute  being  one  of  the  miracles  as- 
signed to  Christ,  he  concludes  by  saying : — "  '  Everything  but  trodden 
out  of  existence,'  is,  in  one  word,  the  fate  of  the  individual  who  has 
been  the  first  Merely  Human  being  to  cause  the  deaf  to  hear." 

Having  many  years  ago  discussed  this  subject,^  it  is  unnecessary  to 
expatiate  upon  it  further.  The  public  should,  however,  be  guarded 
from  these  impostures,  which  are  from  time  to  time  offered  for  the 
cure  of  incurable  diseases ;  among  these,  deaf-dumbness — some  cases 
of  which  are  now,  I  understand,  undergoing  a  series  of  mesmeric 
experiments — is  one  of  the  most  fruitful. 

The  various  Cyclopaedias  of  Medicine  published  in  Great  Britain 
contain  articles  upon  aural  diseases ;  among  these.  Dr.  Copland's 
"  Dictionary  of  Practical  Medicine,"  Article,  Ear  and  Hearing,  Parts 
III.  and  IV.,  may  be  specially  noticed,  as  embodying  a  compilation 
of  the  opinions  of  the  best  authors  on  the  subject.  T.  Chevalier 
published  in  London  a  treatise  "  On  the  Cure  of  Polypi  in  the  Meatus 
Auditorius  Externus  with  Sulphate  of  Zinc,"  in  1843;  I  have  not, 
however,  seen  the  book. 

With  respect  to  the  Irish  manuscripts  to  which  reference  was  made 
at  p.  23,  it  could  not  be  expected  that  works  of  that  early  date  would 
afford  much  information  on  an  art  which  has  within  the  last  few  years 
only  been  raised  to  the  level  of  surgical  and  medical  science.  Several 
of  these  manuscripts  contain  curious  receipts  for  deafness,  consisting 
chiefly  of  the  juice  of  herbs,  prepared  according  to  a  particular  for- 
mula, and  dropped  into  the  external  meatus ;  among  which  the  roots 

'  "  Contributions  to  Aural  Surgery,  Part  II.,  The  Early  History  of  Aural  Surgery,  with 
a  Nosological  Chart  of  Diseases  of  the  Ear." — Dublin  Journal  of  Medical  Science  for 
July,  1844. 


AMERICAN    WRITERS  —  THE    EDINBURGH    SCHOOL.      59 

and  flowers  of  cowslip  and  the  red  mesmir  mixed  with  honey,  occur 
frequently ;  saffron  and  burdock  boiled  on  vinegar,  and  roasted  figs, 
were  much  employed ;  and  eel  oil  was  then,  as  it  is  still,  a  favorite 
popular  receipt  for  deafness.  In  the  Book  of  the  O'Lees  there  is  a 
chapter  devoted  to  the  consideration  of  diseases  of  the  ear,  but,  like 
most  of  the  other  writings  of  that  period,  it  consists  chiefly  of  an 
enumeration  of  the  "  cures"  in  most  general  use  for  deafness. 

I  am  not  acquainted  with  any  native  American  work  on  aural  sur- 
gery ;  and  the  medical  periodicals  of  that  country  have  recorded  but 
few  cases  of  interest  in  connexion  therewith.  The  only  book  which 
I  know  is  that  of  Saissy,  "  An  Essay  on  the  Diseases  of  the  Internal 
Ear,  translated  from  the  French,  by  Nathan  R.  Smith."  Baltimore, 
1829.^  The  first  volume  of  Baron  Larrey's  "  Clinique  Chirurgicale,'" 
containing  a  chapter  on  Lesions  of  the  Ear,  was  translated  by  Dr. 
Bivinus,  of  Philadelphia,  in  1832. 

Edinburgh  has  not  contributed  much  towards  aural  surgery.  I 
know  of  but  one  special  work  on  diseases  of  the  ear  which  has  issued 
from  the  Press  of  that  ancient  and  celebrated  School  of  Medicine 
since  the  time  of  Degravers,  viz.,  "Treatise  on  the  Accessary  Organs 
of  Hearing,  comprising  the  Special  Pathology  and  Treatment  of  their 
Diseases,  by  James  Mercer,  M.D.,"  which  was  written,  I  understand, 
as  a  probationary  essay  for-  the  Fellowship  of  the  College  of  Sur- 
geons, in  1840.  In  the  Monthly  Journal  for  March,  1848,  will  be 
found  a  very  useful  paper  on  the  pathological  sequences  of  acute  in- 
flammation of  the  fibro-mucous  structure  of  the  cavity  of  the  tym- 
panum, by  the  same  author. 

In  the  Monthly  Journal  of  Medical  Science  for  1845  and  1846, 
Dr.  A.  Warden,  "Aurist  in  Ordinary  to  the  Queen,"  published  papers 
on  the  Inspection  of  the  Meatus  Auditorius  Externus.  This  gentle- 
man fixed  to  the  ordinary  tubular  speculum  a  prism  for  the  purpose 
of  polarizing  light, — a  totally  useless  addition.     In  1847  he  promised 

'  [Dr.  Smith's  translation  contains  a  supplement  of  seventeen  pages  octavo,  by  him, 
on  "  Diseases  of  the  External  Ear,"  and  "  a  description  of"  his  "  instrument  for  perforating 
the  membrana  tympani."  Besides  the  above,  there  is  an  American  edition  of  Pilcher, 
with  notes  (chiefly  confined  to  the  physiology  of  hearing),  published  by  Barrington  & 
Haswell,  Philadelphia,  1843. 

There  was  a  reprint,  in  1838,  of  Dr.  Bennett's  translation  of  Kramer,  by  Thomas, 
Cowperthwait  &  Co.,  of  Philadelphia,  and  one  of  Dufton's  book,  by  Lea  &  Blanchard, 
in  1848.  There  was  also  a  duodecimo  of  124  pages,  entitled  "A  Treatise  on  the  Ana- 
tomy, Physiology,  and  Diseases  of  the  Ear,"  by  James  Bryan,  M.D.,  of  Philadelphia, 
published  by  the  author  in  1851. — A.  H.] 


60  REQUISITES    FOR    AN"    AURAL    SURGEON. 

a  work  on  the  subject,  of  which  the  following  is  the  advertisement, 
as  it  appeared  in  one  of  the  Scotch  newspapers: — "In  the  Press,  and 
shortly  will  be  published,  the  Nature  and  Treatment  of  Diseases  of 
the  Ear,  as  more  fully  revealed  by  the  Prismatic  Auriscope ;  with 
fifty  colored  Delineations  of  Natural  and  Diseased  Conditions. — 
'  With  the  Prism  in  our  hand  we  may  now  go  forward  as  with  a  torch 
powerful  enough  to  dispel  all  obscurity,  and  to  enable  and  entitle  us 
to  plant  the  union-jack  of  the  profession  on  the  whole  domain  in  the 
usual  forms  of  maps  and  delineations  of  disease.' — Pre/ace. "Neither 
work  nor  preface  ever  appeared,  and  criticism  of  the  dead  would  now 
be  ungenerous. 

While  these  pages  are  passing  through  the  Press,  Mr.  Harvey,  of 
London,  whose  writings  have  been  already  alluded  to  at  p.  47,  has 
issued  another  work,  entitled,  "Rheumatism,  Gout,  and  Neuralgia,  as 
affecting  the  Head  and  Ear ;  with  Remarks  on  some  forms  of  Head- 
ache in  connexion  with  Deafness."  In  it  the  author  appears  to  be 
under  the  impression  that  he  is  entitled  to  originality  for  his  views. 
My  answer  to  that  will  be  found  in  Chap.  V. 

The  literature  relating  to  deaf-dumbness  will  be  considered  in  the 
section  bearing  on  that  subject. 

What  is  the  legitimate  aural  practitioner  in  the  present  day,  and 
how  far  does  his  art  extend  over  disease  ?  A  practitioner  in  aural 
surgery,  or,  if  it  pleases  the  public  to  call  him,  an  Aurist,  in  our  day 
must,  or  at  least  he  ought  to  be,  a  well-educated  surgeon  or  physi- 
cian, who  applies  the  recognised  principles  of  medicine  and  surgery 
to  diseases  of  the  organs  of  hearing,  in  the  same  manner  as  the 
modern  ophthalmic  sm-geon  does  to  diseases  of  the  eye.  We  daily 
hear  and  read,  and  it  has  been  reiterated  from  mouth  to  mouth,  and 
copied  from  work  to  work,  that  the  treatment  of  such  affections  is 
an  opprobrium  to  the  healing  art,  "m  surditate  quidnam  est  male,'' 
and  that  deafness  is  without  the  pale  of  human  knowledge.  Now 
notwithstanding  the  injudicious  treatment  by  quacks  and  nostrum- 
mongers,  the  neglect  of  patients,  and — as  in  many  instances  we  know 
it  is — the  total  abandonment  of  all  treatment  by  the  general  practi- 
tioner, still,  were  the  statistics  of  all  diseases  carefully  collected,  it 
would  be  found  that  there  were  among  them  as  many  curable  cases 
of  affections  of  the  ear  as  there  are  among  the  severer  maladies  of 
the  eye,  or  among  diseases  of  the  chest,  the  brain,  the  liver,  or  any 
other  organ.  Up  to  a  very  recent  period,  from  well-educated  medical 
men  in  this  country  either  considering  it  beneath  their  station  or  ac- 


REQUISITES    FOR    AN    AURAL    SURGEON.  61 

quirements  to  treat  so  insignificant  an  organ  specially,  or  not  finding 
in  the  direct  cultivation  of  aural  surgery  a  sufficient  remuneration 
for  their  time  and  talents,  tMs  branch  of  the  healing  art  remained 
in  the  state  in  which  ophthalmic  surgery  was  half  a  century  ago.  All 
this — added  to  the  smaller  share  of  sympathy  affiarded  to  the  deaf 
than  the  blind ;  to  impaii-ment  of  hearing  interfering  less  with  man's 
means  of  subsistence,  and  also  to  the  great  difficulty  of  either 
minutely  examining  dm-ing  life,  or  of  investigating  after  death,  the 
morbid  changes  which  occur  in  the  middle  and  internal  ear — serves 
to  account  for  aural  surgery  and  pathology  not  having  kept  pace 
with  the  other  rapid  improvements  in  medical  science.  Yet  the  well- 
instructed  aurist  of  our  time  possesses  a  knowledge  and  a  power 
which  is  not  general  among  the  profession — of  making  an  accurate 
diagnosis,  which,  when  given  with  honesty,  will  frequently  save  the 
patient  much  anxiety,  unnecessary  suffering,  and  loss  of  time  and 
money. 


62 


CHAPTER    11. 

MEANS   OF   DIAGNOSIS,  AND   APPLICATION   OF   REMEDIES. 

Plan  of  the  Work. — Records  of  Cases. — Means  of  forming  a  Diagnosis,  and  mode  of 
Examination. — Pliysical  Signs. — Instruments  and  Remedies. — The  Auditory  Canal 
and  Membrana  Tympani. — Lamps,  the  various  forms  of. — The  Speculum. — Eusta- 
chian Catheterism. — The  Stethoscope. — Syringing.  —  The  Hearing  Distance. — The 
Throat.  —  The  Voice.  —  Tinnitus. — Subjective  Symptoms.  —  Depletion.  —  Leeches. — 
Counter-Irritation. — Galvanism  and  Electricity. — Mercury,  &c. 

Having  in  the  preceding  chapter  offered  some  remarks  upon  the 
subject  of  Aural  Surgery  generally,  and  given  a  short  outline  of  the 
history  of  the  art,  I  will  now  explain  the  plan  which  I  have  adopted 
in  the  following  chapters.  At  the  commencement  of  each  I  have 
given  a  brief  anatomical  description  of  the  parts  concerned  in  the 
affections  under  consideration,  and  a  concise  account  of  their  most 
remarkable  malformations  and  congenital  diseases ;  afterwards,  the 
etiology  and  treatment  of  those  diseases  with  which  I  am  myself 
most  familiar  are  described.  I  have  followed  that  division  into  the 
diseases  of  the  external,  middle,  and  internal  ear,  because  it  seems  to 
facilitate  description,  as  well  as  to  make  the  most  lasting  impression 
on  the  mind  of  the  student.  The  work  concludes  with  a  section  on 
deaf-dumbness,  which  contains  the  result  of  the  inquiry  set  on  foot 
under  the  Irish  Census  Commission  for  1851,  and  which  I  have  com- 
pressed from  the  official  Report  upon  the  subject  lately  presented  to 
Parliament.^ 

From  1843  to  the  present  time  I  have  published  several  essays 
and  monographs  on  diseases  of  the  ear  in  the  Dublin  Journal  of 
Medical  Science,  the  Dublin  Quarterly  Journal,  and  the  London 
Medical  Times.^     The  substance  of  these  essays,  modified  by  sub- 

'  See  also  the  Author's  paper  on  the  Statistics  of  Deaf-dumbness,  communicated  to 
the  British  Association  at  Belfast,  September,  1852. 

2  The  earliest  of  these  essays — Upon  the  Causes  and  Treatment  of  Otorrhoea, — that  by 
which  the  tubular  speculum  was  first  introduced  in  this  country, — appeared  in  the  First 


RECOKDS    OF    CASES.  63 

sequent  knowledge,  and  amplified  by  whatever  improvements  had 
been  made  in  the  art  since  their  publication,  I  have  reprinted  in  this 
work.  Those  diseases  of  the  ear  with  which  I  am  not  myself  ac- 
quainted I  have  briefly  enumerated  and  described,  and  given  the 
references  for  their  authenticity. 

In  an  art  but  just  emerging  from  the  mists  of  quackery,  which 
have  until  recently  enveloped  the  pathology  and  treatment  of  dis- 
eases of  the  ear,  it  is  of  great  importance  to  accumulate  facts,  and 
openly,  fairly,  and  fearlessly  to  state  the  truth,  even  at  the  expense 
of  what  is  termed  popular  reputation.  Observing  in  the  periodicals, 
from  time  to  time,  records  of  "cures"  of  deafness,  and  aural  affec- 
tions, which  evidently  prove  their  authors  to  be  unacquainted  with 
the  ordinary  pathological  appearances  of  such  diseases ;  and  more- 
over, seeing  daily  "causes  of  deafness"  put  forward  in  books  and 
papers,  which,  according  to  my  experience,  rarely,  if  ever,  exist ; 
and  furthermore,  hearing,  and  having  continually  brought  under  my 
notice  (although,  curious  to  relate,  generally  by  persons  who  are 
themselves  incurably  deaf),  accounts  of  success  in  the  treatment  of 
deafness  in  other  parts  of  the  United  Kingdom,  which  I  do  not  and 
cannot  credit ; — I  determined  to  make  an  accurate  note  of  every  case 
of  disease  of  the  ear  among  the  patients  who  applied  at  the  Hospital 
for  twelve  months  in  succession.  I  believe  it  to  be  of  the  greatest 
importance,  in  the  present  state  of  our  knowledge,  to  accumulate 
facts,  and  to  make  the  profession  at  large  acquainted  with  the  ap- 
pearances which  any  deviation  from  the  normal  or  healthy  state 
presents  in  the  ear ;  and  I  have  also  thought  it  useful  to  familiarize 
the  pupils  attending  the  Institution  over  which  I  am  placed,  with 
those  methods  of  examination  which  will  best  enable  them  to  form  an 
accurate  diagnosis  and  prognosis. 

Series  of  the  Dublin  Medical  Journal,  for  January,  1844,  vol.  xxiv.,  p.  318,  as  Part  I,  of 
"  Contributions  to  Aural  Surgery."  This  Essay,  which  met  with  a  very  favorable  recep- 
tion on  the  Continent,  was  translated  into  German,  and  published  separately  by  Dr.  Von 
Hasselberg,  of  Stralsund,  in  1846,  and  afterwards  large  portions  of  it  were  translated  by 
Dr.  Schmalz,  of  Dresden,  in  1848.  Part  II. — Upon  the  Early  History  of  Aural  Surgery, 
with  a  Nosological  Chart  of  Diseases  of  the  Ear,  already  referred  to  at  page  58 — was 
published  in  the  same  periodical  for  May,  1844.  Part  III. — On  the  Inflammatory 
Affections  of  the  Membrana  Tympani  and  Middle  Ear — 'Was  printed  in  the  Dublin 
Quarterly  Journal  of  Medical  Science,  No.  VIII.,  for  November,  1847,  and  No.  XL,  for 
February,  1848.  The  Practical  Observations  on  Diseases  of  the  Ear,  with  the  records 
of  cases  alluded  to  in  the  text,  were  commenced  in  the  Medical  Times  for  March  29th, 
1851,  and  have  been  continued  until  the  present  time. 


64  RECORDS    OF    CASES. 

Each  case,  as  it  presented,  was  accurately  investigated  in  the  pre- 
sence of  a  class  of  advanced  students  and  young  medical  men ;  the 
most  prominent  symptoms  were  noticed,  the  pathological  condition  of 
the  parts  demonstrated,  and  a  few  remarks  made  upon  the  cause  of 
the  disease,  its  prognosis  and  treatment.  Occasionally  the  students, 
under  my  direction,  conducted  the  examination.  A  short-hand  writer, 
familiar  with  medical  terms,  who  was  always  in  attendance,  recorded 
with  accuracy  what  passed.  These  notes,  when  reduced  to  writing, 
I  myself  corrected,  and  frequently  compared  with  the  appearances 
presented  upon  the  patient's  next  attendance.  By  this  means  a  vast 
amount  of  time  and  labor  was  saved,  and  the  diseases  being  thus  noted 
by  myself,  without  the  usual  intervention  of  a  "  case-taker,"  I  believe 
them  to  be  more  accurate  than  those  usually  related  in  medical  writ- 
ings. By  this  means  a  vast  amount  of  information  was  collected.  In 
most  of  these  clinical  cases  a  running  comment  is,  as  might  be  expected, 
mixed  up  with  the  description, — a  more  colloquial,  but  perhaps  not 
less  useful,  form  of  instruction  than  that  commonly  met  with  in  medi- 
cal books  and  periodicals. 

As  far  as  progress  and  the  effects  of  treatment  are  concerned,  many 
of  these  cases  are  very  defective,  because,  in  a  large  public  Institu- 
tion, as  every  one  knows  who  is  extensively  engaged  in  treating  the 
poor,  it  is  not  possible  to  follow  out  their  history.  Several  of  the 
persons  applying  for  relief,  having  little  hope  held  out  of  ultimate 
restoration  to  perfect  hearing,  do  not  return  a  second  time ;  others 
are  kept  away  by  their  respective  avocations ;  and  many  of  them, 
having  changed  their  residence,  have  found  it  inconvenient  to  attend. 
Unsatisfactory  as  these  drawbacks  are,  and  must  always  be  under  the 
like  circumstances,  I  think  the  publication  of  an  abstract  of  these 
cases  will  be  so  far  useful,  by  enabling  the  profession  to  judge  from 
what  causes  deafness  most  usually  arises,  and  what  morbid  appearances 
most  commonly  present.  Some  of  these  cases,  exhibiting  types  of 
disease,  have  already  appeared  in  the  "Medical  Times." 

In  noting  these  cases,  in  some  instances  the  objective,  and  in  others 
the  subjective  symptoms,  have  been  first  recorded ;  but  the  accounts 
which  even  educated  people  give  of  the  history  of  their  deafness  are 
frequently  most  incongruous,  and  often  puzzling ;  and  the  apathy  and 
indifference  with  which  persons  in  all  ranks  of  life  have  allowed  the 
insidious  approaches  of  aural  disease  to  creep  upon  them  are  really 
marvellous.  Mr.  Saunders,  with  whose  valuable  essay  upon  the  ear 
I  wish  the  profession  were  better  acquainted  than  they  are,  remarked 


METHOD     OF    EXAMINATION: THE     AURICLE.  65 

upon  this  subject,  in  his  own  peculiar  lucid  manner  of  expressing  him- 
self, nearly  half  a  century  ago: — "A  clear  and  distinct  recital  of 
symptoms  is  rarely  obtained  from  the  deaf.  They  are  conscious  of 
their  infirmity,  but  very  few  are  impressed  with  a  notion  that  hearing 
may  be  impaired  by  a  variety  of  causes.  The  approach  of  deafness 
is  insidious,  and  often  unaccompanied  with  pain.  Few  strong  impres- 
sions are  made  on  the  mind  of  the  patient,  and  he  loses  his  faculty  of 
hearing  so  imperceptibly,  that  in  general  his  friends  sooner  discover 
his  misfortune  than  himself." 

With  respect  to  the  mode  of  conducting  the  inquiry  in  the  Hospital 
cases,  I  may  remark,  that  where  a  patient  presented  with  a  totally 
incurable  disease,  a  second  note  has  rarely  been  recorded ;  indeed, 
the  patient  has  always  been  discouraged  attending  the  Institution. 
It  is  less  likely  to  bring  discredit  upon  the  art  when  people  are  honestly 
told  that,  owing  to  their  own  neglect,  or  to  their  improper  treatment, 
the  time  has  passed  by  for  affording  them  relief,  than  to  allow  them 
to  continue  for  weeks  or  months  in  attendance,  and  often  at  a  great 
expense  of  time.  This  observation  holds  good  in  private  practice 
even  more  than  in  the  management  of  institutions,  or  in  treating  the 
poor. 

As  in  all  diseases,  so  especially  in  aural  affections,  the  first  grand 
point  is  accuracy  of  diagnosis,  without  which  all  treatment  must  be 
empirical,  and  to  arrive  at  which  it  is  indispensably  necessary  that  we 
should  be  thoroughly  acquainted  with  the  best  mode  of  conducting  an 
examination.  For  that  reason,  and  because  it  is  in  it  I  find  both  the 
practitioner  and  student  most  frequently  at  fault,  I  have  in  the  follow- 
ing pages  dwelt  at  greater  length  and  entered  more  minutely  into 
that  part  of  the  subject,  than  is  usual  in  works  of  this  description. 

Passing  for  the  present  the  subjective  symptoms,  which  will  best 
appear  in  the  words  of  the  patient,  let  us  inquire  into  the  best  method 
of  forming  a  diagnosis  from  the  physical  signs  presented.  The  pa- 
tient being  placed  opposite  strong,  direct  sunlight, — with  the  head 
inclined  at  such  an  angle  that  the  sun's  rays  may  fall  directly  through 
a  tubular  speculum  upon  the  membrana  tympani, — we  first  carefully 
observe  the  condition  of  the  concha,  external  meatus,  mastoid  process, 
infrazygomatic  region,  and  the  space  immediately  below  the  lobe  of 
the  ear.  The  auricle,  in  its  various  folds,  its  color,  its  temperature 
in  particular,  its  thickness  as  learned  by  feeling  its  hem  or  helix  be- 
tween the  fingers,  and  the  angle  which  it  forms  posteriorly  with  the 
cranium, — together  with  the  position,  size,  shape,  and  color  of  the  exter- 

5 


66 


THE     MASTOID     REGION. 


nal  meatus,  as  seen  wittiout  altering  the  relation  of  the  parts — should 
be  specially  noticed.  The  upper  rim  of  the  helix  should  then  be  grasped 
between  the  finger  and  thumb  of  one  hand,  and  drawn  upwards,  back- 
wards, and  outwards,  while  the  thumb  of  the  other  hand,  placed  in 
front  of  the  tragus,  by  drawing  it  and  the  integuments  forward  upon 
the  zygoma,  exposes  the  outer  third  or  more  of  the  auditory  canal 
to  view.     This  little  gorget-like  instrument  will  also  be  found  useful 

in  examining  the 
Fig- 1-  external      aper- 

ture. The  finger 
should  then  be 
pressed  deeply 
and  firmly  upon 
the  movable  root 
of  the  tragus,  and  backwards  into  the  depression  between  it  and 
the  articulation  of  the  jaw.  While  the  finger  is  retained  in  this  posi- 
tion the  patient  should  be  desired  to  open  and  shut  the  mouth,  and  the 
amount  6f  pain  or  inconvenience  experienced  by  pressure  in  those  two 
different  positions  of  the  jaw  accurately  noted.  The  middle  and  fore- 
fingers should  likewise  be  inserted  deeply  behind  the  ramus  of  the 
jaw  towards  the  styloid  process,  and  notice  taken  of  the  sensations 
there  experienced. 

Where  we  have  reason  to  believe  inflammatory  action  exists,  the 
mastoid  process  in  an  especial  manner  claims  our  attention.  Its  color, 
size,  shape,  and  temperature,  may  be  learned  by  even  a  cursory  ex- 
amination ;  but,  besides  this,  it  should  be  most  carefully  pressed  upon 
with  a  couple  of  fingers,  with  a  much  greater  degree  of  force  and 
firmness  than  is  usual  in  making  examinations  of  the  like  nature  else- 
where ;  and  this  examination  should  not  only  be  applied  to  the  mas- 
toid region,  but  to  the  whole  posterior  and  lateral  portion  of  the  head, 
if  we  have  reason  to  suspect  any  inflammation,  or  its  effects.  The 
insertion  of  the  sterno-mastoid,  as  well  as  the  upper  third  of  that 
muscle,  should  also  be  carefully  examined  in  the  same  way,  as  there 
is  a  small  gland,  in  shape  and  size  like  a  horse-bean,  situated  imme- 
diately behind  the  auricle,  over  the  middle  of  the  mastoid  process, 
which  frequently  becomes  enlarged  during  the  progress  of  aural  in- 
flammations, and  is  also  the  seat  of  violent  neuralgic  pain  in  some  in- 
stances. If  the  integuments  and  soft  parts  are  swollen  or  oedematous, 
as  is  frequently  the  case  in  certain  inflammatory  affections  of  the  ear, 
as  also  where  they  have  become  thickened  from  long-continued  dis- 
ease, it  will  require  a  considerable  degree  of  force  to  make  a  perfectly 


THE     EXTERNAL    AUDITORY     CANAL.  67 

satisfactory  examination.  The  amount  of  pitting  made  by  the  finger 
during  this  examination  and  its  degree  of  permanency,  are  also  cir- 
cumstances of  value  in  the  formation  of  a  diagnosis.  Percussion  of 
the  mastoid  process,  immediately  behind  the  attachment  of  the  auricle, 
occasionally  affords  some  information,  as  will  be  shown  in  some  of  the 
cases  hereafter  detailed. 

We  next  proceed  to  inquire  into  the  condition  of  the  auditory  canal, 
and  external  surface  of  the  membrana  tympani.  To  effect  this,  and 
to  explore  every  portion  of  the  surface  of  these  parts,  it  is  necessary 
to  resort  to  the  mechanical  assistance  of  the  speculum  ;  first  taking 
care  to  remove  any  impaction  of  wax,  accumulated  discharge,  or 
other  mechanical  impediment  which  may  exist  and  obstruct  om-  vision. 
If  this  obstruction  is  complete,  and  we  have  reason  to  suppose 
that  it  is  the  chief  cause  of  deafness,  the  employment  of  a  syringe 
and  some  plain  warm  water  is  the  best  mode  of  removing  it ;  but  if 
the  obstruction  merely  co-exists  with  other,  and  particularly  with  some 
of  the  inflammatory  affections  of  the  meatus  or  tympanal  membrane, 
or  if  it  be  only  partial,  and  consists  of  portions  of  detached  cuticle, 
hairs,  or  scales  of  hardened,  inspissated  cerumen,  it  is  better  to  re- 
move these  gently  with  a  paii-  of  fine  forceps,  because  the  very  act  of 
syringing,  even  with  warm  w^ter,  causes  in  a  healthy  ear  an  increased 
vascularity,  which  will  mask  the  actual  amount  of  disease  present. 
The  same  observation  applies  also  with  respect  to  slight  otorrhoea, 
but  if  there  be  much  discharge  present,  we  must  have  recourse  to  the 
syringe.  Having  found  that  the  handles  of  the  instruments  intro- 
duced through  the  tubular  speculum  and  the  fingers  of  the  operator 
interfere  to  a  certain  degree  with  the  direct  sun-rays,  I  have  latterly 
had  instruments  constructed  with  an  angle  in  the  shaft,  as  shown  in 
the  accompanying  view  of  a  pair  of  ear  forceps,  the  utility  of  which 
is  at  once  manifest. 

Fig.  2. 


Up  to  a  very  recent  period  we  possessed  no  better  means  of  examin- 
ing the  external  meatus  and  the  membrana  tympani  than  that  afforded 
by  the  usual  ear  speculum,  made  somewhat  in  the  form  of  a  crane- 


68  THE     DIFFERENT     KINDS     OF     LAMPS. 

bill  forceps,  and  derived,  with  various  modifications,  from  the  time  of 
Fabricius  Hildanus.  Itard,  Deleau,  Verret,  Robbi,  Kramer,  and 
others,  have  improved  upon  this  speculum,  which  was  that  in  general 
use  in  this  country  until  I  introduced  the  tubular  form  in  my  Essay 
on  Otorrhoea.  Another  description,  with  three  arms,  and  opening 
by  a  screw  in  the  form  of  a  vagina  speculum,  was  manufactured  by 
Mr.  Weiss,  on  the  supposition  that  the  external  auditory  passage 
could  be  increased  in  calibre  by  mechanical  means,  and  Hoffman  has 
published  an  account  of  a  somewhat  similar  instrument  in  "  Casper's 
Wochenschrift"  for  1841.  In  making  examinations  of  the  meatus 
and  membrana  tympani  with  any  of  these  instruments,  the  chief  re- 
quisite is  a  strong  direct  light,  transmitted  without  interruption  to  the 
tympanal  membrane,  or  that  portion  of  the  passage  which  we  wish  to 
examine.  This  is  best  eflfectedby  means  of  the  sun's  rays,  but  as  the 
ordinary  speculum  can  only  dilate  or  straighten  the  external  cartila- 
ginous portion  of  the  passage,  a  person  accustomed  to  aural  exami- 
nations can  frequently,  especially  where  the  meatus  is  of  a  large 
size,  observe  the  tympanal  membrane,  or  at  least  a  portion  of  it, 
without,  as  well  as  with,  such  an  instrument,  by  merely  lifting  up  the 
auricle  with  one  hand  and  pressing  the  tragus  forward  with  the  thumb 
of  the  other.  The  light  must,  however,  be  strong,  and  made  to  fall 
directly  upon  the  passage.  In  all  such  examinations  the  patient 
should  be  seated  beneath  the  examiner,  with  the  head  slightly  bent, 
opposite  a  window  through  which  the  sun  is  shining  at  the  moment, 
and,  if  possible,  between  the  hours  of  eleven  and  three. 

Artificial  light  has  been  recommended,  but  it  is  not  so  requisite  in 
this  as  in  other  countries.  In  Vienna,  for  instance,  during  the  winter 
months,  there  are  many  days  on  which  there  is  not  sufficient  light  for 
accurate  aural  examinations.  Cleland  used  a  convex  glass,  which  was 
held  before  a  wax  candle,  in  order  to  concentrate  the  rays  of  light 
into  the  meatus.  To  this  apparatus  Bozzini  added  a  concave  mirror, 
but  without  much  effect;  Deleau  further  modified  it  by  placing  a 
lighted  taper  between  two  concave  mirrors.  The  invention  of  the 
instrument  of  this  description  which  possesses  greatest  power  is  un- 
doubtedly due  to  our  countryman,  Buchanan,  the  principle  of  whose 
lamp  exhibits  an  evident  acquaintance  with  the  laws  of  light,  and  the 
mechanism  of  optical  instruments.  This  was  subsequently  improved 
upon,  and  its  effects  increased  by  Kramer,  who  substituted  an  argand 
lamp  for  the  comparatively  feeble  wax-light  of  the  original  inventor. 
This  instrument,  which  in  form,  construction,  and  effect,  very  nearly 
resembles  a  common  magic  lantern,  consists  of  a  tin  box,  having  its 


THE     DIFFERENT     KINDS     OF    LAMPS.  69 

interior  blackened,  and  being  provided  with  a  strong  lamp  and  power- 
ful reflector,  opposite  which  there  is  a  tube  containing  two  convex 
lenses,  each  two  inches  and  half  in  diameter.     In  using  this  appa- 
ratus, a  disk  of  strong  light,  about  the  size  of  a  halfpenny,  is  thrown 
upon  the  opening  of  the  meatus,  a  portion  of  which  light  is,  by  means 
of  any  of  the  ordinary  specula  straightening  the  cartilaginous  por- 
tion of  the  tube,  transmitted  to  the  membrane  of  the  drum.     Now, 
independent  of  the  inconvenience  of  this  lamp,  I  may  remark  that, 
although  it  undoubtedly  illuminates  the  passage  and  membrane  very 
powerfully,  yet  the  peculiar  Imid  glare  which  it  throws  upon  every 
object  decidedly  prevents  the  examiner  observing  with  accuracy  those 
conditions   of  the  parts — as  in  inflammation,  &c. — where  color  and 
the  character  of  the  vascular  arrangement  form  the  chief  means  of 
true  diagnosis;   and  even  Kramer  himself  is  forced  to  acknowledge 
that  "no  artificial  illumination  can  equal  the  light  of  the  sun's  rays, 
or  render  this  light  unnecessary,  on  which  account  it  must  always 
be  had  recourse  to  in  important  cases,  e.  g.,  in  operations  in  the 
vicinity  of  the  membrana  tympani."     All  lamps  possess  these  two 
radical  defects :  One  is,  that   although  an  irregularity  of  surface,  a 
polypus,  an  aperture  in  the  membrana  tympani,  or  the  like,  may  be 
detected,  yet  shades  of  vascularity  produced  by  inflammation  or  con- 
gestion, speckled  opacities,  minute    points  of  morbid  deposit,   and 
slight  ulcerated  abrasions,  want  of  polish,  and  loss  of  transparency, 
&c.,  cannot  be   detected  by  their  means.     And  again,  although  we 
are  able  to  detect  an  ulcer,  a  granulation,  or  a  perforation,  we  could 
not  be  able,  while  the  eye  is  fixed  upon  the  spot,  to  apply  any  direct 
remedy  to  the  part  afi"ected, — or  pass  down  a  porte-caustic,  a  for- 
ceps, a  snare,  or  a  camel-hair  brush.     How,  for  instance,   could  a 
hair,  no  uncommon  cause   of  annoyance,  be  removed  ofi"  the  surface 
of  the  drum  through  one  of  these  lamps  ?     No  obstetric  practitioner 
thinks  of  examining  the  os  uteri  or  the  surface  of  the  vagina  with  a 
lamp,  so  long  as  the  sun's  rays  can  be  directed  through  a  tubular 
speculum  to  the  parts  affected. 

The  instrument  which  I  have  here  described  is  now  generally  known 
imder  the  name  of  Kramer's  ear  lamp.  Buchanan's  apparatus  is 
represented  in  his  "Illustrations  of  Acoustic  Surgery,"  and  all  the 
various  lamps  and  forms  of  specula  are  figured  in  Lincke's  Sandhuch 
cler  OhrejidheilJcunde,  and  in  Frank's  Practische  Anleitung,  page  -38 
to  61.  In  most  modern  English  works,  however,  we  find  a  cop-^ 
perplate  of  ear  instruments,  particularly  those  of  Kramer,  Lincke, 


70  THE    TUBULAR    SPECULUM. 

and  Sclimalz,  but  in  addition,  though  without  much  difference,  we  see 
a  figure  of  "the  author's  catheter,"  "the  author's  lamp,"  &c.,  &c. 

Two  portable  ear  lamps  have  been  produced  in  England  within  the 
last  few  years,  one  by  Mr.  Jordan  of  Manchester,  a  very  ingenious 
instrument,  and  useful  when  artificial  light  is  either  applicable  or 
alone  available,  as  at  night,  or  in  a  sick-room  when  the  patient  can- 
not be  moved  to  the  light  with  facility.  It  consists  of  a  small  box, 
containing  a  lighted  taper  and  two  metallic  reflectors,  one  of  which  is 
set  at  an  angle  in  the  bend  of  a  projecting  arm,  which  throws  a 
stream  of  light  on  the  membrana  tympani,  through  a  fixed  tubular 
speculum  inserted  into  the  meatus,  while  the  operator  looks  through 
a  narrow  tube  containing  two  small  lenses ;  but,  like  all  such  instru- 
ments, it  is  objectionable  on  account  of  the  peculiar  red  glare  it 
throws  upon  the  parts  under  inspection.  Mr.  Averey's  reflector, 
which  is  a  very  well-constructed  instrument,  is  also  liable  to  the  same 
objection. 

In  1827  Dr.  Newburg,  in  his  Memoir  et  Observations  sur  la  Per- 
foration'de  la  Membrane  du  Tympan,  published  at  Brussels,  recom- 
mended a  slender  horn  tube,  nearly  four  inches  long,  with  a  bell 
muzzle.  This  instrument,  which  is  much  too  long,  was  the  origin  of 
the  different  varieties  of  tubular  specula  now  in  use.  Subsequently 
Dr.  Gruber,  of  Vienna,  improved  upon  Newburg's  idea,  and  to  him 
I  am  indebted  for  the  instrument  of  which  I  published  an  account  in 
1844. 

Having  found  that  all  the  instruments  heretofore  invented  for  ex- 
ploring or  operating  upon  the  external  auditory  passages  were  defec- 
tive, as  a  means  of  transmitting  light,  which  is  the  only  real  object 
of  a  speculum, — for  it  is  a  mistake  to  suppose  that  any  apparatus 
can  do  more  than  straighten  and  dilate  the  external  aperture  and 
external  third  of  the  tube, — I  have  always  employed  the  tubular  spe- 
culum for  this  purpose.  This  little  instrument,  formed  upon  the 
principle  of  that  invented  by  Dr.  Newburg,  and  described  in  the 
preceding  paragraph,  I  first  saw  used  by  Dr.  Gruber,  but  employing 
it  as  he  did  with  the  artificial  light  of  Kramer's  lamp,  he  had  not  the 
same  opportunities  of  testing  its  value  and  utility.  These  instru- 
ments consist  of  conical  silver  tubes  of  different  calibres,  such  as 
those  represented  in  the  accompanying  wood-cut,  each  tube  or  specu- 
lum being  an  inch  and  a  half  long,  five-eighths  of  an  inch  wide  at 
the  greater  aperture,  and  varying  from  two  to  four  lines  in  the  clear 
at  the  smaller  extremity.  Larger  and  smaller  sizes  will  be  occasion- 
ally necessary,  but  for  the  greater  convenience  of  carrying  in  the 


THE     TUBULAR     SPECULUM.  71 

pocket,  I  generally  order  a  set  of  three,  formed  so  as  to  fit  into  one 
another,  and  corresponding  in  size  to  the  representations  below. 
They  should  be  made  as  light  as  possible,  highly  polished  both  inside 
and  out,  with  a  stout  rim  or  burr  round  the  larger  margin,  and  the 
smaller  aperture  well  rounded  off,  so  as  not  to  irritate  the  ear  in 

Fig.  3.  Fig.  4.  Fig.  5. 


entering.  I  have  tried  them  of  various  sizes  and  shapes,  and  their 
sides  running  at  different  angles,  as  well  as  with  the  interior  black- 
ened, so  as  to  prevent  reflection  of  the  incident  luminous  rays,  but 
those  which  I  have  described  above  I  find  to  answer  the  purpose 
best.  In  using  this  speculum,  the  various  sizes  of  which  are  adapted 
to  different  ages  and  varieties  of  aural  aperture,  the  patient  must,  if 
possible,  be  seated  opposite  the  light,  and  the  head  placed  at  such  an 
angle  as  that  when  the  instrument  is  introduced  into  the  meatus,  the 
rays  of  light  will  fall  directly  through  it  upon  the  membrana  tym- 
pani.  While  the  auricle  is  drawn  upwards  and  backwards  with  one 
hand,  this  little  tube  is  inserted  into  the  meatus  with  the  other,  and 
is  pushed  in  as  far  as  possible  without  giving  pain ;  the  head  of  the 
patient  and  the  tube  also  are  then  moved  slightly  from  side  to  side, 
and  the  inclination  or  obliquity  of  the  latter  altered  till  a  full  stream 
of  light  falls  upon  the  tympanal  membrane.  In  making  this  exami- 
nation the  operator  must  be  careful  to  keep  his  own  head  out  of  the 
light,  the  interference  of  which  is  a  very  frequent  cause  of  failure 
with  those  unaccustomed  to  aural  examinations ;  the  shadow  of  the 
head  should  fall  a  little  above  or  a  little  below  the  sphere  of  the  spe- 
culum, according  to  the  sun's  elevation  at  the  moment ;  and  I  need 
hardly  mention  that  but  one  person  can  make  this  exploration  at  a 
time.  As  the  tube  is  generally  arrested,  in  normal  ears  at  least,  by 
the  narrow  portion  of  the  meatus  at  the  junction  of  its  middle  and 
external  thirds,  we  may  then,  by  gently  rotating  and  moving  from 


72  THE    TUBULAR    SPECULUM. 

side  to  side  the  larger  aperture,  which  is  held  between  the  fingers, 
direct  the  stream  of  light  so  as  to  play  upon  any  part  in  particular 
all  round  the  meatus,  immediately  external  to  the  memhrana  tympani, 
and  by  withdrawing  it  slightly,  each  portion  of  the  passage  may  be 
thus  accurately  examined  in  detail.  By  this  means  every  part  of  the 
external  auditory  tube,  and  the  membrana  tympani,  and  even  the 
position  of  the  malleus  within  it,  may  be  as  distinctly  seen  and  as 
carefully  examined  as  any  portion  of  the  external  surface  of  the  eye ; 
whereas,  with  the  ordinary  hinge-moving  speculum,  I  have  in  many 
cases  been  unable  to  satisfy  myself  as  to  the  exact  condition  of  the 
membrana  tympani ;  and  that  this  is  daily  experienced  by  surgeons, 
I  have,  in  addition  to  their  own  acknowledgments,  the  fact  of  cases 
constantly  presenting  themselves,  in  wliich  a  diagnosis  had  been  made 
as  to  the  state  of  the  membrana  tympani,  totally  at  variance  with 
truth,  and  which  arose  from  their  inability  to  see  and  examine  it  with 
the  usual  instruments.  To  attempt  any  degree  of  dilatation  of  the 
auditory  passage  by  means  of  instruments  shows  a  want  of  anatomical 
knowledge  in  their  inventors,  as  the  most  any  speculum  can  effect  is 
to  straighten  the  external  cartilaginous  portion  of  the  tube,  and 
thereby  allow  the  light  to  play  upon  the  interior.  Had  the  accurate 
and  honest-minded  Saunders  possessed  this  means  of  examining  the 
ear,  he  certainly  would  not  have  stated  that  he  had  "  never  observed 
these  excrescences"  (polypi  and  granulations)  "in  the  meatus  exter- 
nus  when  the  tympanum  was  sound."  Another  great  advantage 
which  this  funnel-like  speculum  possesses  over  all  others  is,  that  it 
remains  fixed  in  the  ear,  causing  scarcely  any  inconvenience,  and 
leaving  one  or  both  hands  free  for  the  application  of  instruments  if 
necessary.  It  is  also  much  more  easily  used  with  young  children 
than  any  other. 

From  a  long  and  most  extensive  use  of  the  tubular  speculum,  I  am 
convinced  that  it  is  not  only  the  simplest,  but  also  the  most  effectual 
instrument  for  examining  the  condition  of  the  membrane  of  the  tym- 
panum and  the  external  auditory  canal.  Various  other  instruments, 
tubes  with  prisms,  such  as  that  invented  by  Mr.  Warden,  and  men- 
tioned at  page  59,^  and  divers  lamps,  have  been  recently  contrived, 
and  their  virtues  set  forth  in  graphic  terms  by  their  inventors  and  sup- 
porters, but  they  are  all  comparative  failures,  because  they  cannot 
enlarge  the  osseo-cartilaginous  portion  of  the  canal  near  the  tympa- 
num ;  and  the  prisms  are  totally  unnecessary,  and  even  disadvanta- 
geous, where  direct  light  can  be  procured. 

'  See  Medical  Gazette  for  24th  May,  1844. 


THE     TUBULAR     SPECULUM.  73 

I  have  dwelt  thus  long  upon  the  subject  of  the  speculum,  because 
without  it  it  is  impossible  to  form  an  accurate  diagnosis,  and  because 
it  is  the  want  of  the  proper  employment  of  this  instrument  which  has 
led  to  such  gross  errors  in  practice.  Modifications  of  it  have  been 
devised  by  others,  and  possibly  in  their  hands  they  may  be  found  more 
useful  than  that  which  I  employ.  I  believe,  however,  it  is  a  well- 
managed  light  (natural,  not  artificial  light),  a  practised  eye,  and  deli- 
cute  manipulation,  that,  more  than  any  peculiar  form  of  instrument, 
assists  the  practitioner  efiectually  to  explore  the  external  auditory 
passage  or  the  middle  ear,  and  which  enables  him  to  make  an  accurate 
diagnosis. 

It  is  no  small  gratification  to  me,  to  find  that  my  labors  to  make 
the  profession  in  this  country  acquainted  with  the  best  method  of  ex- 
amining the  ear  have  been  attended  with  some  success.  An  ear  spe- 
culum has  now  become  a  necessary  appendage  to  the  assortment  of 
instruments  which  a  surgeon  usually  carries  about  with  him,  while  but 
a  few  years  ago  such  a  thing  was  unknown — in  this  kingdom  at  least. 
People  are  also  beginning  to  find  out  that  something  may  be  done  for 
deafness,  and  that  therefore  it  is  worth  while  attending  to  diseases  of 
the  ear  in  the  beginning.  I  do  not  expect  that  the  prejudices  of  cen- 
turies will  be  got  rid  of  in  a  day,  nor  the  neglect  of  years  recovered 
in  an  hour ;  but  I  have,  within  the  last  three  or  four  years,  observed 
a  manifest  improvement  in  the  mode  of  treating  diseases  of  the  ear 
among  all  classes  of  the  profession. 

The  form,  curvature,  color,  polish,  vascularity,  and  the  secretion 
of  the  entu'e  auditory  canal  should  be  accurately  noted,  and  having 
brought  the  whole  of  the  passage  and  the  entire  of  the  membrana 
tympani  under  our  view,  we  must  take  accurate  note  of  their  relative 
positions.  In  this  case  we  suppose  the  external  conduit  free  from  ac- 
cumulation of  wax,  muco-purulent  discharge,  or  other  impediment 
that  might  obstruct  our  view.  Should,  however,  such  exist,  they  must 
be  now  removed,  in  order  that  we  may  gain  a  clear,  uninterrupted 
sight  of  the  parts  they  cover.  Without  any  abnormal  secretion,  how- 
ever, we  often  meet  with  so  much  cerumen  as  partially  interferes  with 
the  examination,  and  this  may  be  gently  removed  with  a  small  spatula 
or  a  probe  rolled  round  with  cotton,  as  by  syringing  in  such  cases  we 
increase  the  vascularity,  and  so  mask  the  natural  appearances. 

The  tympanal  membrane,  in  an  especial  manner,  claims  our  atten- 
tion ;  not  only  its  superficial  color,  but  its  degree  of  transparency  or 
opacity,  its  tenuity  or  thickening,  its  vascularity,  and  the  arrange- 
ment and  position  of  its  vessels  in  every  part, — its  tension,  flexibility, 


74  EXAMINATION     OF    THE     MEMBRANA    TYMPANI. 

polish,  curvature,  and  its  position  as  regards  the  interior  of  the  cavity, 
of  which  it  forms  the  outward  boundary, — and  also  the  direction  and 
projection  of  the  handle  of  the  malleus,  and  the  characters  of  the 
membrane,  both  above  and  below  the  attachment  of  this  bone,  should 
be  carefully  observed.  While  the  membrane  is  thus  within  the  field 
of  the  speculum,  the  patient  should  be  desired  to  try  and  press  air 
into  the  drum  by  holding  the  nose,  shutting  the  mouth,  and  making  a 
forced  expiration.  This  manoeuvre  should  be  resorted  to  several  times, 
if  the  first  be  ineffectual,  as  some  degree  of  tact  on  the  part  of  the  pa- 
tient is  necessary  to  test  the  experiment.  The  sound  thus  produced 
is  a  sort  of  thug,  and  very  much  resembles  that  of  a  dried  bladder 
suddenly  inflated  with  air.  In  order  to  become  familiar  with  it,  one 
should  practise  it  on  himself.  While  the  air  is  thus  pressed  into  the 
drum  we  should  note  accurately  whether  the  membrane  vibrates,  or 
its  tensity  is  altered,  and  if  so,  whether  it  regains  its  original  position 
suddenly  or  gradually.  The  patient's  own  sensations  should  likewise 
be  taken  into  account  in  this  matter.  It  is  also  necessary  carefully 
to  observe  the  degree  of  vascularity  produced  by  this  inflation,  as  well 
as  the  course  and  position  of  the  vessels  which  cause  such  vascularity, 
for  even  in  several  healthy  ears,  if  this  experiment  is  made  two  or 
three  times,  we  seldom  fail  to  recognise  one  or  two  vessels  becoming 
filled  with  red  blood  along  the  course  of  the  malleus ;  and  if  a  small 
aperture  exists  in  the  membrane  which  may  have  previously  escaped 
the  eye,  we  may  then  readily  detect  it  both  by  sight  and  hearing. 
By  this  means  we  often  discover  a  perforation,  which,  from  its  minute- 
ness, or  owing  to  the  part  being  thickened  or  coated  with  discharge, 
had  not  been  noticed  during  the  ocular  inspection.  If  such  exist,  we 
shall  then  see  its  open,  everted  lips  sometimes  pressing  out  mucous 
discharge,  and  also  hear  a  peculiar  whistling  sound  which  the  air 
makes  in  passing  through  this  narrow  aperture.  There  are,  hoAvever, 
some  cases  of  perforate  membrana  tympani,  where,  from  obstruction 
in  the  upper  part  of  the  Eustachian  tube,  or  granulations  in  the  middle 
ear,  this  cannot  be  efi'ected.  If  the  patient  be  able  to  inflate  the  tym- 
panum by  this  method,  we  may  then  remove  the  speculum,  and,  ap- 
plying our  own  ear,  either  directly  or  through  the  intervention  of  a 
stethoscope,  placed  over  the  external  auditory  passage,  the  same 
method  of  inflation  should  be  again  had  recourse  to,  and  the  pecu- 
liarity of  sound  which  is  thus  produced  in  the  middle  ear,  whether 
the  ordinary  normal  rush  of  air,  or  a  prolonged  squealing  or  gurgling 
sound,  such  as  might  be  caused  by  any  contraction  in  or  thickening 
of  the  walls  of  the  Eustachian  tube,  or  by  dryness,  or  by  accumula- 


A  u  s  c  r  L  T  A  T  I  0  X.  75 

tion  of  mucus  either  in  it  or  in  the  cavity  of  the  tympanum,  is  heard. 
The  stethoscope  should  also  be  applied  over  the  mastoid  process,  and 
the  same  series  of  observations  made  upon  the  sounds,  if  any,  pro- 
duced there ;  but  these  latter  can  seldom  be  heard  distinctly. 

If  the  patient  be  unable  to  inflate  the  tympanum,  and  we  have 
reason  to  suspect  some  obstruction  of  the  Eustachian  tube,  or  an 
accumulation  of  mucus,  blood,  pus,  or  other  matter,  in  the  middle 
ear,  we  may  then,  should  the  case  require  it,  proceed  to  inject  air, 
by  the  mechanical  means  of  a  pump,  an  elastic  tube,  and  a  catheter, 
into  the  cavity  of  the  tympanum,  while  we  carefully  note  the  result 
by  means  of  a  stethoscope,  or  by  the  ear  applied  externally.  It 
must,  however,  be  particularly  borne  in  mind,  that  if  the  patient  is 
laboring  at  the  time  under  acute  inflammation  of  the  drum  or  its 
membranes,  or  the  lining  of  the  Eustachian  tube,  the  catheter  is  not 
only  inapplicable,  but  highly  injui'ious.  I  have  latterly  found  it 
very  seldom  necessary  to  resort  to  this  operation,  as  the  cases  in 
which  it  is  applicable  are  of  much  greater  rarity  than  is  usually  sup- 
posed, or  as  the  works  of  aurists  would  lead  us  to  believe.  Still,  as 
exploration  through  the  naso-tympanal  passage  is  a  valuable  means 
of  diagnosis,  it  should  be  here  described.  The  early  history  of  the 
operation  has  been  detailed  at  page  26.  A  great  variety  of  instru- 
ments and  several  ingenious  machines  have  been  invented  for  injecting 
atmospheric  air,  gases,  medicated  vapors,  and  fluids,  into  the  middle 
ear  through  the  Eustachian  tube.  These  consist  of  catheters  of 
different  curves  and  calibres,  and  formed  of  flexible  and  inflexible 
materials,  and  a  great  diversity  of  complicated  mechanical  apparatus 
for  pressing  air  or  fluids  through  these,  from  a  simple  bladder  or 
elastic  bag,  or  a  bellows,  to  an  air-press,  which  compresses  and  con- 
denses a  certain  volume  of  atmospheric  air  by  means  of  a  forcing- 
pump  into  a  chamber  furnished  with  a  stop-cock,  to  which  the  catheter 
may  be  connected  through  the  medium  of  a  flexible  tube.  That 
devised  by  Kjamer,  and  figured  in  his  work,  is  by  far  the  best 
and  most  easily  managed.  The  pump  which  I  am  in  the  habit 
of  using  was  manufactured  for  me  in  1841  by  Mr.  Weiss,  and 
is  figured  at  page  79.  It  may  not  be  so  easily  managed  as  that  of 
Kramer,  in  which  the  piston  rod  is  worked  by  a  long  lever,  but  it 
possesses  the  advantage  of  having  the  receiver  quickly  and  more 
efiectually  charged.  This  instrument  is  fourteen  inches  high,  exclu- 
sive of  the  piston  rod,  and  four  and  a  half  in  diameter.  The  cylinder 
of  the  force-pump,  which  rises  above  the  surrounding  receiver,  and 
passes  into  it  for  about  two-thirds  of  its  depth,  is  provided  with 


76 


THE  EUSTACHIAN  CATHETER. 


rig.  6. 


^' 


valves  througli  which  the  air  is  accumulated  in  the  latter  to  the 
required  extent.  Generally  six  or  seven  actions  of  the  piston  is 
sufficient  for  this  purpose. 

The  catheter  which  I  am  in  the  habit  of  using 
with  adults  is  that  here  figured  of  the  natural  size ; 
smaller  ones  may  be  required,  but  a  silver  instrument 
like  this,  well  smoothed  and  rounded  at  the  point, 
and  of  as  large  a  size  as  can  with  facility  be  intro- 
duced through  the  nose,  is  less  likely  to  do  mischief, 
causes  less  irritation,  is  less  liable  to  catch  in  the 
mucous  membrane,  and  is  more  apt  to  adjust  itself 
to  the  bell  or  trumpet-shaped  mouth  of  the  Eustachian 
tube,  than  one  of  a  smaller  size,  or  composed  of  a 
flexible  material.  Even  the  elastic  cathether  can 
only  be  introduced  with  a  stilette,  the  withdrawal 
of  which  causes  considerable  irritation,  and  generally 
disadjusts  the  point  of  the  instrument.  Some  people 
even  at  the  present  day  assert  that  the  catheter  can  be 
introduced  through  the  mouth,  and  others  recommend 
it  to  be  passed  above  the  lower  turbinated  bone  of 
the  nose.  And  again  we  hear  it  stated  that  the 
instrument  being  once  fixed  in  the  Eustachian  tube, 
it  will  remain  there,  or  the  patient  may  be  directed 
to  hold  it  in  that  position  until  an  inflated  bladder, 
a  bellows,  a  syringe,  or  a  gum-elastic  bag,  charged 
with  fluid,  is  attached  to  its  extremity,  and  the  con- 
tents discharged  through  it  into  the  middle  ear.  It 
would  occupy  too  much  space  to  enter  minutely  into 
the  objections  to  each  of  these  statements  or  modes 
of  proceeding.  I  do  not  believe  they  are  generally 
feasible,  and  this  is  an  opinion  in  which  I  am  sure 
the  most  experienced  aural  surgeons  will  agree  with 
me.  Along  the  floor  of  the  nose  is,  in  the  first  in- 
stance, the  most  ready  access  to  the  Eustachian  tube ; 
but,  supposing  that  we  have  passed  the  instrument 
with  the  greatest  facility,  and  are  quite  sure  that  the 
beak  has  turned  into  its  faucial  opening,  we  must 
always  bear  in  mind  that  not  much  more  than  half, 
or  at  most  three-quarters,  of  an  inch  of  the  curved  por- . 
tion  of  the  instrument  has  passed  up  into  the  tube,  and  that  the  slightest 
movement  on  the  part  of  the  patient,  either  of  the  anterior  naris,  which 


CATHETER  ISM     OF    THE     EUSTACHIAN    TUBE.  7T 

is  irritated  by  the  foreign  body,  or  the  top  of  the  pharynx,  where 
all  the  parts  concerned  in  deglutition  are  more  or  less  strained  and 
excited,  may  disadjust  the  instrument.  The  slightest  effort  at  deglu- 
tition, even  the  act  of  swallowing  the  saliva,  will  often  effect  this,  as 
we  may  perceive,  by  observing  the  alteration  in  the  position  of  the 
ring  at  the  end  of  the  catheter  which  projects  beyond  the  nose.  It 
fortunately  so  happens,  that  nausea  is  seldom  produced  if  the  instru- 
ment has  been  carefully  and  delicately  introduced.  In  ordei^ 
however,  to  obviate  the  difficulties  which  I  have  just  referred  to,  and 
to  keep  the  instrument,  when  once  properly  adjusted,  fixed  in  the 
right  place,  mechanical  contrivances  have  been  devised,  of  which  a 
sort  of  vice — the  plate  of  which  is  fastened  upon  the  forehead,  imme- 
diately above  the  root  of  the  nose,  by  means  of  a  leather  strap  fur- 
nished with  a  buckle,  which  passes  round  the  head — is  the  handiest. 
Upon  the  front  of  the  metallic  plate  is  a  ball-and-socket  joint,  in 
which  revolves  the  little  vice,  or  forceps,  which  is  set  on  at  a  right 
angle,  and  should  come  down  over  the  anterior  opening  of  the  nose. 
The  patient  being  seated  in  a  chair  with  the  head  supported  against 
a  high  back,  specially  constructed  for  the  purpose,  and  the  frontlet 
put  on  as  I  have  described, — with  the  forefinger  of  the  left  hand 
elevate  the  point  of  the  nose,  and  then  with  the  right  hand  insert  the 
catheter,  with  its  beak  turned  outward  into  the  angle  between  the 
floor  and  external  wall  of  that  cavity ;  passing  it  rapidly  over  the 
floor  of  the  nose,  a  dexterous  and  well-practised  operator  will  fre^ 
quently  hitch  it  into  the  sulcus  of  the  Eustachian  opening  at  the  first 
attempt,  and  is  conscious  of  the  fact  by  that  taetus  eruditus  which 
nothing  but  extensive  experience  can  give,  but  which  it  is  very  difficult 
to  describe.  We  can  often  feel  the  catheter  grasped  by  the  mouth  of 
the  Eustachian  tube.  If,  however,  we  have  missed  the  aperture,  we 
must  push  on  the  catheter  until  it  is  arrested  by  the  back  of  the 
pharynx  ;  then  turn  the  beak  downwards,  and  withdraw  the  instru- 
ment a  little,  until  its  concavity  hitches  against  the  edge  of  the  hard 
palate,  and  then,  again  making  a  slight  sweep,  and  turning  the  beak 
outwards  and  a  little  upwards,  and  at  the  same  time  pushing  it 
slightly  in  and  out,  and  thus  feeling  for  the  opening,  we  will,  after  a 
little  practice,  succeed  in  our  attempt.  We  must,  however,  remember 
that  we  have  to  deal  with  parts  which  vary  in  length  and  calibre  in 
different  individuals.  We  may  always  be  aware  of  the  direction  of 
the  beak  by  looking  to  the  ring  at  the  end  of  the  catheter,  as  they 
are  both  on  the  same  plane.     We  may  now  be  conscious  that  the 


78  CATHETERISM     OF    THE    EUSTACHIAN    TUBE. 

instrument  lias  acquired  the  desired  position,  and  that  its  beak  is  in 
the  pharyngeal  extremity  of  the  Eustachian  tube ;  but  yet,  until  we 
make  a  further  experiment  with  a  jet  of  air,  we  are  not  perfectly 
certain  that  it  is  in  the  exact  position  which  we  desire,  as  the  open 
extremity  of  the  instrument  may  be  pressing  against  the  thickened 
or  flaccid  mucous  membrane  of  the  part.  Now  let  us  suppose  that 
the  instrument  has  gone  in  with  facility,  that  the  patient  'is  steady, 
and  has  a  well-formed  nose,  and  has  not  expressed  any  sign  of  un- 
easiness,— we  must  not,  however,  let  him  speak,  for  the  very  act  of  so 
doing  might,  until  the  instrument  is  properly  fixed,  disadjust  its 
point. 

There  is  much  variety  in  the  nasal  organ,  and  in  a  great  number 
of  instances  the  septum  is  not  in  the  middle  line :  I  have  met  cases 
in  which  the  vomer  leaned  over  to  one  side,  generally  the  left,  so  that 
the  aperture  was  too  narrow  for  the  passage  of  the  instrument ;  and 
in  other  cases  the  lower  spongy  bone  came  down  so  low,  and  en- 
croached so  much  upon  the  nasal  cavity,  that  a  similar  obstruction 
was  produced.  The  chief  point  of  irritation  is  at  the  anterior  ex- 
tremity of  the  nose,  and  therefore  it  is,  that  we  must  press  up  its 
point  with  the  finger  of  the  left  hand,  and  also  pass  the  instrument 
with  rapidity  over  this  portion  of  its  transit.  If  the  operation  be 
properly  conducted,  it  is,  though  an  unpleasant  sensation,  by  no 
means  painful,  and  even  sneezing  is  seldom  produced ;  but  there  is 
another  symptom  which  almost  invariably  attends  the  introduction  of 
the  catheter,  that  is,  lachrymation ; — we  constantly  see  a  tear  flow- 
ing over  the  cheek ;  it  is  not  the  effect  of  pain,  otherwise  both  eyes 
would  weep,  for  it  seldom  or  never  occurs  except  upon  the  side  on 
which  we  are  operating,  and  it  appears  to  be  the  eflect  of  irritation 
of  the  mucous  membrane  continuous  with  the  conjunctiva  and  con- 
veyed along  the  course  of  the  excretory  lachrymal  duct.  It  is  usual 
to  warm  the  catheter  by  holding  it  near  the  fire,  or  rubbing  it  briskly 
through  the  fingers ;  but  as  the  parts  over  which  it  passes  are  always 
well  lubricated  with  mucus,  and  do  not  grasp  the  instrument  like  the 
urethra,  I  do  not  think  it  necessary  to  oil  the  catheter,  as  some  re- 
commend. 

Having  proceeded  thus  far,  turn  down  the  clams  or  forceps,  and, 
leaving  the  catheter  free  for  a  moment,  grasp  it  with  the  blades  of 
the  former,  and  screw  home  the  nut  which  tightens  them,  and  then 
fix  the  apparatus  by  means  of  the  screw  which  arrests  the  motion  of 
the  ball-and-socket  joint  upon  the  forehead  plate.     Upon  a  small 


APPLICATION     OF    THE     AIR-PKESS.  79 

table  in  front  of  the  patient  is  placed  the  air-press,  the  mechanism  of 
which  has  been  already  explained,  and  which  had  been  previously 
charged,  and  to  which  the  elastic  tube,  about  two  feet  in  length,  is 
screwed  by  a  stop-cock  communicating  with  the  receiver.  To  the 
other  extremity  of  the  tube  is  fixed  a  small  brass  ferule  which  fits 
into  the  end  of  the  catheter,  in  connecting  it  with  which  considerable 

Fig.  7. 


care  and  nicety  is  required.  The  catheter  being  held  between  the  finger 
and  thumb  of  the  left  hand,  the  ferule  should  be  delicately  but 
firmly  inserted  into  it  with  the  right.  An  assistant  or  the  patient 
should  then  hold  up  this  connecting  tube,  lest  its  weight  might  dis- 
adjust  the  catheter's  point;  the  position  of  the  ring  at  the  other  end 
of  which  will  always  show  its  position.  This  ring  should  point  out- 
wards and  a  little  upwards,  nearly  on  a  line  with  the  external  meatus, 
but  the  angle  which  it  makes  with  the  horizon,  supposing  the  patient 
to  sit  in  a  natural,  erect  position,  will  very  much  depend  upon  the 
formation,  and  especially  the  length,  of  the  external  naris.  The 
above  illustration  shows  the  application  of  the  apparatus,  and  serves 
to  explain  the  foregoing  description. 

Before  we  apply  the  ear  or  the  stethoscope  to  the  patient's  ear, 
we  should  partially  turn  the  stop-cock,  so  as  to  let  a  little  air  pass 
through ;  for  frequently,  especially  if  the  patient  is  at  all  nervous, 
the  first  jet  of  air  may  cause  him  to  start,  and  perhaps  to  derange 
the  catheter.     The  operator  should  now  apply  the  bell'd  extremity  of 


80  AURAL     AUSCULTATION. 

the  stethoscope  over  the  concha,  by  which  means  its  bore  is  almost 
directly  over  the  external  meatus ;  and  having  applied  his  ear  to  the 
other  end  of  it,  he  should  turn  the  stop-cock  of  the  air-press  with  his  own 
hand,  and  thereby  regulate  with  greater  precision  the  force  and  volume 
of  the  stream  of  compressed  air  which  passes  up.  By  this  mode  of 
manipulation  alone  am  I  convinced  of  the  fact  of  the  air  passing  into 
the  cavity  of  the  middle  ear ;  and,  until  this  test  is  applied,  I  do  not 
believe  that  any  one  can  say  with  certainty  that  the  air  has  freely 
passed  up. 

In  a  healthy  ear,  with  a  free  tube,  when  a  stream  of  air  is  passed 
into  the  tympanum  after  this  fashion,  it  impinges  upon  the  inner  wall 
of  the  membrana  tympani  with  a  peculiar  thug,  followed  by  a  con- 
tinuous rustling  sound,  which  is  very  remarkable,  and,  once  heard,  is 
not  easily  forgotten.  This  is  the  natural  sound,  and  deviations  from 
it,  caused  by  stricture,  or  obstruction  of  the  Eustachian  passage,  by 
a  diseased  condition  of  the  membrane  lining  the  middle  ear,  or  by 
collections  of  mucus,  pus,  or  other  fluids  in  that  cavity,  produce  ab- 
normal sounds  of  a  squealing,  rasping,  or  a  gurgling  character,  which 
are  of  value  in  diagnosing  aural  affections.  These  sounds  may  per- 
haps in  time  be  reduced  to  some  degree  of  order,  and  we  should 
familiarize  ourselves  with  them,  so  that  if  possible  we  may  be  able  to 
test  and  appreciate  their  value.  Laennec  was  well  acquainted  with 
the  phenomena  of  these  sounds,  and  anticipated  that  auscultation 
would  become  a  useful  adjunct  in  determining  not  merely  the  condi- 
tion of  the  Eustachian  tube,  but  also  the  state  of  the  tympanum. 

We  should  now  place  the  patient  in  such  a  position  that  we  may 
have,  through  the  ordinary  tubular  speculum,  a  clear  view  of  the  ex- 
ternal surface  of  the  membrana  tympani,  and  we  shall  then  perceive, 
that  when  we  permit  a  jet  of  air  to  reach  the  cavity  of  the  tym- 
panum, it  presses  outwards  the  anterior  and  lower  portion  of  the 
membrane, — that  which  is  most  vibratory  and  placed  opposite  the 
stream  of  air, — and  also  that  it  at  the  same  time  renders  the  upper 
and  posterior  part  of  the  membrane  slightly  vascular. 

Were  we  to  allow  too  great  a  stream  to  pass  through  the  tube,  the 
desired  object  would  not  be  effected ;  the  current  of  air,  not  able  to 
find  entrance  through  the  Eustachian  tube,  would  force  back  and  dis- 
adjust  the  mouth  of  the  catheter  with  a  loud  gurgling  noise,  like  that 
heard  when  gargling  the  throat,  and  cause  considerable  annoyance 
and  even  pain  to  the  patient  by  its  regurgitation.  Therefore  it  is 
that  the  operator  should  with  his  own  hand  regulate  the  force  of  the 


CATHETEEISM  OF  THE  EUSTACHIAN  TUBE.      81 

current,  while  at  the  same  time  he  listens  to  its  effect  upon  the 
ear. 

To  remove  the  instrument  we  must  proceed  with  the  same  caution 
and  delicacy  with  which  we  introduced  it ;  first  by  gently  separating 
the  connecting  tube  from  the  catheter ;  then  freeing  the  latter  from 
the  blades  of  the  vice  or  forceps,  and,  having  pulled  it  forward  a 
short  distance,  the  beak  should  be  turned  downward  and  the  instru- 
ment so  withdrawn. 

This,  then,  is  the  operation  about  which  we  have  heard  so  much, 
and  from  which  death  is  said  to  have  occurred  in  two  instances  in 
London,  some  years  ago.  Simple  and  easy  of  performance,  however, 
as  it  now  seems,  I  must  suppose  that  it  is  occasionally  performed  with 
roughness,  and  even  violence.  I  remember  a  few  years  ago  seeing 
a  dragoon  officer,  who  labored  under  mucous  accumulation  of  the  ears, 
and  as  he  was  himself  unable  to  force  air  into  the  tympanal  cavity, 
it  was  deemed  advisable  to  resort  to  the  operation  which  has  been 
just  described.  Accordingly  I  desired  an  assistant  to  bring  in  the 
air-press,  while  I  proceeded  to  arrange  the  other  preliminaries,  merely 
informing  the  patient  that  it  was  necessary  to  make  an  examination 
which  would  put  him  to  a  little  inconvenience,  but  not  cause  any  pain. 
He  eyed  the  preparations  with  considerable  anxiety,  and  at  last  ex- 
claimed, "  Oh !  I  know  now  what  you  are  going  to  do,  and  I  am  de- 
termined not  to  have  that  thing  rammed  up  my  nose  again ;  for  the 
last  time  it  was  done  I  was  put  to  such  pain  and  bled  so  much  that  I 
fainted."  We  have  known  such  things  occur  to  rough  and  ignorant 
practitioners  in  their  endeavors  to  force  a  catheter  into  the  bladder, 
and  the  mention  of  this  circumstance  is,  I  feel,  sufficient  to  put  us  on 
our  guard ;  and  I  think  I  need  scarcely  add,  that,  where  such  force 
and  violence  as  that  detailed  by  this  gentleman  were  employed,  the 
original  object  of  the  operation  could  not  have  been  attained. 

We  have  all  heard  a  great  deal  about  catheterism  of  the  Eustachian 
tube — of  the  marvellous  and  instantaneous  effects  attributed  thereto, 
of  the  accidents  which  may  occur,  and  of  the  difficulties  which  beset 
the  operator  in  his  endeavor  to  introduce  an  instrument  into  the  fau- 
cial  opening  of  the  passage  which  leads  into  the  middle  ear.  I  know 
few  subjects  upon  which  there  is  more  general  ignorance  than  the 
value  to  be  attached  to  Eustachian  catheterism,  or  the  best  mode  of 
employing  it.  Some  writers  would  lead  us  to  suppose  that  this  opera- 
tion is  of  use  in  a  far  greater  number  of  aural  diseases  than,  accord- 
ing to  my  experience,  is  the  fact.     In  order  to  facilitate  our  diag- 


82  THE     EUSTACHIAN     BOUGIE. 

nosis,  they  would  have  us  explore  the  middle  ear  by  the  air  douche, 
a  jet  of  water,  or  a  solid  instrument,  in  almost  every  case  that  pre- 
sents. Errors  of  commission  are,  in  both  medicine  and  surgery,  I 
believe,  of  much  greater  injury  than  those  of  omission ;  and  the  in- 
troduction of  a  foreign  body  into  the  Eustachian  tube,  forcing  a 
volume  of  cold  air,  or  injecting  a  quantity  of  fluid,  even  warm  water, 
into  the  cavity  of  the  middle  ear,  as  some  recommend  and  say  they 
practise,  is,  in  nearly  all  cases,  while  inflammatory  action  is  going 
forward  in  the  parts  submitted  to  the  process,  unnecessary  and  fre- 
quently injurious.  Again,  the  mode  in  which  I  have  heard  both  pa- 
tients and  bystanders  speak  of  instruments — catheters  of  various 
kinds,  gum-elastic,  and  metallic,  and  even  solid  sounds,  some  of  the 
latter  much  larger  than  the  bore  of  the  aural  end  of  the  Eustachian 
tube  even  in  the  dry  bone — being  introduced  into  the  middle  ear,  in 
order  to  explore  that  cavity,  to  wash  out  its  contents,  or  to  break  up 
collections  of  mucus  within  it,  or  to  dilate  strictures  and  contractions 
of  the  tube  itself,  convinces  me  that  the  desired  object  was  not,  fortu- 
nately for  the  sufi"erers,  obtained.  Even  Kramer  speaks  of  pushing 
a  catgut  bougie,  introduced  through  the  Eustachian  tube,  "between 
the  handle  of  the  malleus  and  the  incus!"  People  are,  however, 
beginning  to  find  that  this  attempt — for  I  know  in  many  cases  it  is 
only  an  attempt — to  force  solid  or  fluid  substances  into  the  cavity  of 
the  drum,  is  as  inefi"ectual  to  remove  deafness  as  the  almost  indis- 
criminate excision  of  the  tonsils — since  preserved  in  pickle-pots — re- 
commended for  a  like  purpose  a  few  years  ago,  has  proved  to  be.  I 
have  heard  of  cases  in  which  the  middle  ear  has  been  said  to  be  ex- 
plored by  such  mechanical  means,  even  in  this  country,  and  I  have 
been  shown  steel  sounds  manufactured  for  the  purpose.  Such  in- 
struments are,  however,  with  the  exception  of  the  tearing  and  in- 
flammation which  they  may  cause  in  the  nasal  extremity  of  the  tube, 
harmless,  for  they  could  not  by  any  possibility,  even  in  the  dead  sub- 
ject, be  passed  through  the  upper  end  of  the  Eustachian  tube.  We 
should  bear  this  rule  ever  in  remembrance  before  exploring  the 
middle  ear ;  it  is  one  which  Sir  A.  Cooper  observed  to  me  many  years 
ago,  and  I  have  ever  since  acted  upon  it: — Whenever  the  patient  is 
himself  able  to  inflate  the  tympanum,  never  use  any  artificial  means 
to  do  so ;  it  is  unnecessary  and  may  be  injurious.  Let  me  to  this 
aphorism  add  another,  to  which  I  have  already  alluded,  and  which 
surgeons  would  do  well  to  remember.  Where  there  is  reason  to  be- 
lieve that  the  cavity  of  the  drum  is  inflamed,  carefully  abstain  from 


INJECTIONS    AND    FUMIGATIONS     OF     THE    TYMPANUM.     83 

all  poking  with  catheters,  or  any  attempt  to  introduce  foreign  sub- 
stances into  that  delicately-organized  portion  of  the  animal  machine. 
As  good  general  surgery  teaches  us  to  avoid  the  introduction  of  instru- 
ments through  an  inflamed  urethra,  or  into  an  irritable  bladder,  so 
ought  judicious  aural  surgery  teach  us  to  abstain  from  meddling  in  the 
cases  to  which  I  have  alluded.  The  only  solid  instrument  with  which  I 
now  ever  venture  to  explore  the  Eustachian  passage,  and  that  for 
only  a  short  distance,  is  an  ivory  bougie,  rendered  flexible  by  having 
the  earthy  matter  removed  by  immersion  in  acid,  and  the  point  of 
which  for  an  inch  at  least  had  been  previously  softened  in  water  so  as 
to  resemble  a  piece  of  gelatine.  A  large  size  catheter  should  be  first 
introduced,  and  the  bougie  passed  up  through  it ;  but  stricture  of  the 
Eustachian  tube  is  so  exceedingly  rare,  and  so  difficult  to  recognise 
during  life,  that  the  surgeon  is  very  seldom  called  on  to  practise  such 
an  operation. 

In  connexion  with  Eustachian  catheterism  should  be  mentioned, 
the  mode  of  injecting  fluids  for  the  purpose  of  washing  out  the  tube 
and  the  middle  ear,  in  case  of  impaction  of  the  former,  or  mucous 
accumulation  in  the  latter ;  and  of  introducing  gases,  etherous  vapors, 
resinous  and  other  volatile  substances,  for  the  purpose  of  altering  the 
condition  of  the  mucous  membrane,  or  stimulating  the  nervous  expan- 
sion on  its  surface.  A  simple  elastic  bag,  with  the  nozzle  adapted  to 
the  end  of  the  catheter,  will,  for  those  who  may  be  inclined  to  prac- 
tise it,  effect  all  that  is  required  or  that  can  be  attained  by  syringing 
out  the  tympanum  :  in  general  I  believe  the  fluid  seldom  reaches  that 
point,  while  it  causes  great  irritation  by  regurgitating  into  the  throat ; 
but  in  order  that  it  may  have  a  fair  chance  of  going  into  the  middle 
ear,  the  catheter  ought  to  be  fixed  by  the  frontlet  as  already  described. 
Supposing  we  may  with  safety  explore  the  Eustachian  tube,  and  en- 
deavor by  artificial  means  to  press  a  column  of  air  or  a  jet  of  fluid 
into  the  middle  ear,  and  thereby  free  it  of  its  extraneous  contents, 
and  restore  to  its  natural  position  the  vibrating  portion  of  the  tym- 
panal membrane,  it  will  be  of  little  avail  to  effect  these  objects, — as 
it  would  be  merely  to  press  out  the  contents  of  the  lachrymal  sac  in 
a  case  of  mucocele,  or  chronic  inflammation  of  the  mucous  membrane 
of  that  cavity, — unless  we  at  the  same  time  make  use  of  such  means, 
both  topically  and  constitutionally,  as  shall  restore  the  healthy  cha- 
racter of  the  lining  membrane,  which  evidently  participates  in  the 
diseased  action,  and  of  which  manifest  traces  are  observable  upon 
the  external  aspect  of  the  membrana  tympani. 


84 


SYRINGING. 


For  vaporizing  the  tympanum  a  variety  of  ingenious  contrivances 
have  been  invented,  especially  by  the  continental  aurists,  consisting 
of  air-tight  jars  containing  gas,  connected  with  the  catheter  by  elastic 
tubes,  or  vessels  shaped  like  retorts,  in  which  the  substances  to  be 
vaporized  are  placed,  fixed  upon  the  ordinary  chemical  stands  over 
spirit-lamps.  These  shall  be  more  particularly  considered  in  the  sec- 
tion relating  to  "nervous  deafness,"  the  disease  for  which  such  fumi- 
gations are  said  to  be  applicable. 

In  the  previous  description  of  the  method  of  examining  the  exter- 
nal and  middle  ear,  it  has  been  presumed  that  the  external  auditory 
conduit  is  free ;  it  may,  however,  and  it  often  does,  happen,  that  we 
are  unable  to  explore  the  passage,  or  obtain  a  view  of  the  membrana 
tympani,  owing  to  obstruction  of  the  former  with  cerumen,  collec- 
tions of  hair,  or  thickened  and  detached  epithelium,  the  muco-puru- 
lent  secretion  consequent  upon  otorrhoea,  or  foreign  bodies  of  any 
description  ;  and  therefore  it  is  sometimes  necessary  to  have  recourse 
to  the  operation  of  syringing  merely  to  assist  our  diagnosis.  Simple 
as  this  operation  may  appear,  and  frequently  as  it  is  resorted  to  by 
uneducated  persons,  it  is  one  which  requires  some  degree  of  tact, 
caution,  and  dexterity,  in  its  performance. 

To  avoid  slopping  in  syringing  the  ears,  I  have  found  the  form  of 
vessel  represented  below  very  useful :  it  is  metallic,  six  inches  long, 
four  broad,  and  two  deep ;  its  concave  part  fits  accurately  the  curve 
beneath  the  lobe  of  the  ear,  and  the  perforated  septum  strains  the 
clean  water  from  the  dirty.  If  held  by  the  patient  in  the  proper 
position,  closely  applied  to  the  cheek,  no  water  can  get  down  by  its 
side. 

FiK.  8. 


The  top  of  the  auricle  should  be  grasped  with  the  left  hand,  and 
drawn  slightly  upwards,  outwards,  and  forwards,  so  as  to  assist  in 


PHENOMENA    ATTENDING    SYRINGING. 


85 


straightening  the  auditory  canal ;  and  then  we  can  inject  a  steady 
stream  of  water,  the  thumb  raising  and  depressing  the  piston  by 
means  of  a  brass  syringe,  capable  of  holding  three  or  four  ounces  of 
fluid,  but  so  constructed,  as  shown  in  the  accompanying  cut, — ^with  a 
pair  of  loops  attached  to  its  upper  extremity,  through  which  the  fore 
and  middle  fingers  are  passed, — that  it  may  be  worked  with  facility 
by  the  right  hand. 

Pig.  9. 


This  instrument  is,  however,  only  suited  to  the  hands  of  a  surgeon. 
The  small  pewter,  bone,  and  glass  syringes  are  really  of  little  or  no 
use.  The  gum  elastic  bag  is  the  safest  for  general  use  ;  but  I  do  not 
think  it  possible  for  any  one  effectually  to  syringe  his  own  ear.^ 

'  [The  accompanying  figure  is  a  representation  of  an  instrument,  invented  about  three 
years  ago,  by  Dr.  S.  P.  Hullihen,  an  eminent  surgeon  dentist  of  Wheeling,  Va.,  to  enable 
patients    themselves,    vi'ithout 

the  aid  of  another  person,   to  Fip- 10- 

syringe  out  the  external  mea- 
tus. It  consists  of  a  cylindrical 
cup  of  metal  about  three  inches 
deep  and  two  and  a  quarter  in 
diameter,  vi^ith  a  semicircular 
piece  cut  out  of  its  edge,  to 
adapt  it  to  the  ear,  and  a  small 
metallic  syringe,  with  a  dia- 
meter of  about  one-half  of  an 
inch.  This  syringe  in  the  first 
instruments  constructed  was 
movable,    and    supported    on 

two  horizontal  rods  running  across  the  cup,  by  means  of  which  it  could  be  slid  forward 
or  back,  according  to  the  will  of  the  operator ;  but  more  recently  the  inventor  has  had 
it  fastened  permanently  in  the  back  part  of  the  cup,  so  as  to  enable  the  patient  to  use 
it  himself  with  more  facility.  The  syringe  has  a  large  opening  at  the  bottom  covered 
by  a  valve,  and  the  nozzle  is  made  to  come  out  from  the  side,  near  the  bottom,  and 
rising  up  to  the  top  is  bent  forward,  so  as  to  project  towards  the  external  meatus.  Dr. 
H.  has  further  improved  his  instrument,  by  adding  a  narrow  rim  to  the  outer  edge  of 
that  portion  which  is  to  be  pressed  against  the  neck,  immediately  under  the  ear.     It 


86        THE     PRACTICES     OF     PROBING    AND     SYRINGING. 

In  some  persons,  syringing,  or  the  mere  introduction  of  a  specu- 
lum, induces  violent  paroxysms  of  coughing ;  in  others,  the  simple 
act  of  injecting  tepid  water  will  produce  syncope,  although  such 
patients  tell  us  that  it  is  not  from  the  pain  they  feel.  The  removal 
of  a  granulation,  or  a  small  polypus  from  the  external  auditory  pas- 
sage, will  at  times  produce  sickness  of  stomach,  weakness,  and  even 
fainting. 

There  is  a  circumstance  connected  with  this  part  of  the  aural  exa- 
mination worthy  of  attention.  We  often  observe  that,  during  the 
removal  of  wax,  in  syringing  or  in  any  way  interfering  with  the 
meatus,  the  patient  is  seized  with  a  fit  of  spasmodic  coughing,  appa- 
rently caused  by  some  irritation  in  the  larynx,  and  we  can  reproduce 
the  phenomenon  simply  by  the  introduction  of  a  probe,  and  touching 
ever  so  gently  a  particular  spot  upon  the  surface  of  the  meatus. 
This  is  not  a  very  unusual  phenomenon,  although  it  cannot  be  pro- 
duced in  all  cases.  I  never  witnessed  it  in  children  or  very  young 
persons ;  it  is  most  common  in  males  of  about  middle  life,  and  is  in 
nowise  connected  with  any  previous  disease  existing  in  the  respiratory 
apparatus.  In  some  persons  the  slightest  touch  of  the  floor  of  the 
external  auditory  passage,  about  midway  between  its  external  outlet 
and  .the  inferior  attachment  of  the  membrana  tympani,  will  bring  on 
violent  irritation  and  spasmodic  action  in  the  larynx.  In  this  case 
also  the  patient  will  generally  tell  us,  upon  inquiry,  that  he  does  not 
experience  pain ;  but  that  the  moment  we  touch  this  very  sensitive 
spot  he  feels  a  tickling  sensation  in  his  throat,  which  immediately  in- 
creases to  the  feeling  one  has  when  "a  bit  is  gone  astray."  What 
the  nervous  connexion  may  be  which  induces  this  has  not  been  fully 
determined,  but  the  fact  is  worthy  of  note.  The  different  degrees  of 
sensibility  of  the  several  parts  of  the  external  ear  are  worthy  of 
remark.  For  further  particulars  on  this  point,  and  also  as  regards 
syringing,  see  the  section  on  Cerumen  in  Chapter  IV. 

The  effort  of  coughing,  sneezing,  blowing  the  nose,  and  deglutition, 

seems  to  me  that  it  could  be  still  further  improved,  by  having  the  syringe  retained  in 
its  place  by  means  of  two  pieces  of  metal  projecting  fj-om  the  inside  of  the  cup  and 
embracing  it,  and  of  a  catch  at  the  top,  w^hich  would  hold  it  firmly,  at  the  same  time 
that  they  would  allow  of  its  being  drawn  out  and  cleansed,  in  case  the  lower  opening 
should  become  obstructed  by  the  accumulation  of  inspissated  cerumen  or  other  matters 
discharged  from  the  ear,  as  will  often  happen  unless  care  be  taken  to  empty  the  cup  of 
its  contents  every  time  there  is  much  matter  removed  from  the  ear. 

For  the  history  of  and  improvements  in  this  instrument  by  Dr.  H.  I  am  indebted  to 
his  friend,  Mr.  E.  B.  Gardette,  of  this  city. — A.  H.] 


THE     HEAKING     DISTANCE.  87 

in  causing  or  increasing  pain,  is  also  to  be  particularly  attended  to, 
if  we  suspect  inflammation  in  the  drum  or  tlie  Eustachian  tube. 

There  are  two  methods  of  examining  the  ear,  on  which,  from  their 
frequency  in  this  country,  I  am  induced  to  make  some  remarks,  in 
the  hope  of  putting  a  stop  to  practices  not  only  useless,  but  in  some 
cases  positively  injurious.  I  allude  to  the  common  habit  of  syringing 
indiscriminately,  and  also  of  probing  the  ears,  without  proper  inspec- 
tion of  the  parts.  The  former  is  of  daily  occurrence  ;  thus  a  patient 
laboring  under  deafness,  or,  what  perhaps  is  worse,  violent  pain  in 
the  ear,  is  examined  either  without  the  assistance  of  a  speculum,  or 
by  means  of  some  of  the  old  divaricating  instruments,  most  probably 
in  a  badly-lighted  apartment, — at  all  events,  without  the  membrana 
tympani  being  brought  into  view,  a  dark  cavity  being  all  that  the  ex- 
plorer is  able  to  perceive ; — it  is  deemed  advisable  to  try  what  might 
come  out  by  squirting  hot  water  into  this  dark  passage  for  a  quarter 
of  an  hour  or  longer ;  but,  nothing  satisfactory  following  this  opera- 
tion, the  diagnosis  that  there  is  no  wax  in  the  ear  is  accordingly 
made.  Now,  there  may  be  a  collection  of  cerumen,  which  may  not 
be  got  rid  of  by  this  operation ;  while,  if  the  cause  of  the  pain  or 
deafness  is  owing  to  an  inflammatory  condition  of  the  auditory  canal 
and  its  membranous  extremity,  a  decided  increase  of  the  symptoms 
is  induced  by  this  useless  and  cruel  proceeding :  and  I  have  frequently 
seen  inflammation  produced  by  unnecessarily  syringing  an  ear  where 
no  wax  was  present. 

The  practice  of  exploring  the  ear  by  means  of  a  probe  I  cannot 
too  strongly  condemn,  and  yet  that  it  is  frequently  resorted  to  sur- 
geons are  well  aware.  To  introduce  a  common  dressing  probe  and. 
press  it  against  the  membrana  tympani,  without  having  that  mem- 
brane fairly  within  view,  and  without  a  speculum  being  introduced, 
but  merely  for  the  purpose  of  satisfying  the  examiner  as  to  whether 
the  membrane  is  perforate  or  not,  is,  I  think,  a  most  unjustifiable 
proceeding. 

The  degree  of  deafness  may  be  learned,  and  the  hearing  distance 
measured,  by  holding  an  ordinary  watch  near  the  external  meatus, 
and  the  distance  at  which  the  tickings  can  be  accurately  counted, 
and  at  which  the  patient  is  conscious  of  an  interval  between  these 
sounds,  should  be  recorded.  To  effect  this  properly,  the  watch  should 
be  approached  gradually  to  the  ear  till  it  gets  within  the  hearing 
point,  and  again  applied  directly  to  the  auricle,  and  gradually  re- 
moved to  some  distance.     Various  instruments,  producing  a  ticking 


88      EXAMINATION  OF  THE  THROAT  AND  NOSE. 

sound  by  means  of  clockwork,  have  been  invented,  by  Schmalz  and 
others,  for  this  purpose,  but  the  watch  is  quite  sujQficient.  We  should 
also  test  the  hearing  with  the  mouth  open  as  well  as  shut ;  and  it  should 
be  tried  both  before  and  after  the  inflation  of  the  tympanum,  as  in 
many  cases  that  act  will  produce  a  very  material  difference  in  the 
amount  of  hearing.  The  watch  should  be  next  applied  both  behind 
and  in  front  of  the  auricle,  and  to  the  forehead,  and  also  placed  gently 
between  the  teeth  of  the  patient,  and  the  amount  of  hearing  thus  ob- 
tained likewise  noted.  It  is  absolutely  necessary,  if  we  wish  to  watch 
the  progress  of  a  case,  not  only  to  conduct  these  observations  with 
great  care,  but  also  to  take  a  written  note  of  the  "hearing  distance" 
the  first  and  each  subsequent  time  we  see  the  patient.  By  this  means 
we  have  the  most  satisfactory  report  of  the  progress  of  the  case,  both 
for  ourselves  and  the  patient.  It  must  be  remembered  that  there  is 
almost  as  great  a  difference  in  the  normal  hearing  as  there  is  in  the 
normal  seeing  distance,  even  among  persons  who  have  never  labored 
under  any  disease  of  the  ear,  and  who  are  not  at  all  conscious  of  any 
defect  of  hearing.  The  degree  of  hearing  with  a  watch  is  sometimes 
deceptive ;  some  patients  who  cannot  hear  a  watch,  or  even  a  clock, 
will  hear  the  voice,  even  in  a  low  tone  ;  but  these  are  the  exceptions 
to  the  rule.  Except  in  cases  of  congenital  or  acquired  deaf-dumb- 
ness, total  deafness  is  a  rare  affection,  much  more  so  than  total  blind- 
ness ;  and  great  variety  exists  with  respect  to  the  amount  of  hearing 
lost,  and  how  the  defect  is  described,  as,  for  instance,  hardness  of 
hearing,  short  hearing,  dulness  of  hearing,  &c. 

While  inquiring  into  the  amount  of  deafness,  and  the  circumstances 
under  which  the  hearing  is  increased  or  diminished,  we  should  learn 
whether  it  be  improved  or  not  when  the  patient  is  exposed  to  loud 
noises,  as  when  standing  in  a  mill,  walking  through  a  crowded  street, 
or  travelling  in  a  carriage  or  on  a  railway.  We  should  also  inquire 
whether  the  hearing  is  better  at  one  time  of  the  day  than  another, 
and  also  whether  it  is  increased  or  lessened  after  meals,  particularly 
dinner. 

The  condition  of  the  throat,  the  arches  of  the  palate,  uvula,  tonsils, 
and  back  of  the  pharynx,  should  next  be  inquired  into,  particularly 
as  regards  the  state  of  the  mucous  membrane,  its  color,  turgescence, 
or  degree  of  relaxation ;  likewise  the  state  of  infiltration  of  the  sub- 
mucous tissue.  The  forefinger  should  then  be  introduced  far  into  the 
mouth,  and  its  point  made  to  press  firmly  upwards  and  outwards  be- 
yond the  arch  of  the  palate,  opposite  the  mouth  of  the  Eustachian 


CHARACTER     OF     THE     VOICE.  89 

tube,  and  notice  taken  of  the  degree  of  pain  or  inconvenience  it  pro- 
duces there  and  in  the  middle  ear.  We  should  also  carefully  examine 
the  state  of  the  membrane  of  the  nose,  for  which  purpose  the  little 
instrument  figured  at  page  66  will  be  found  useful. 

Something  may  be  gleaned  from  the  character  of  the  voice,  as  few 
instances  occur  of  intense   or  long-continued  deafness  without  that 
function  exhibiting  manifest  symptoms  of  the  defect  of  hearing  to  a 
greater  or  less  extent.     This  defect  does  not  seem  to  be  produced  by 
any  visible  alteration  in  the  parts  engaged  in  the  mechanism  of  speech ; 
it  often  takes  place  without  any  enlargement  of  the  tonsils,  elongation 
of  the  uvula,  or  other  abnormal  condition  of  the  throat,  larynx,  or 
mouth.     There  is  a  peculiarity  of  voice  and  speech  attendant  upon 
deafness  approaching  somewhat  to  the  condition  and  character  of  ar- 
ticulation which  the  deaf-mute  educated  according  to  the  vocal  system 
presents,  and  which  once  heard  is  seldom  forgotten.     The  voice,  from 
not  being  perfectly  heard  by  the  patient  himself,  loses  its  sonorous 
intonation,  and  becomes  hoarse  and  inharmonious,  or  harsh  and  husky, 
with  a  metallic  twang.     In  time  the  patient  loses  the  power  of  modu- 
lation, and  often  appears  to  labor  under    that    defect,   commonly, 
though  incorrectly,  denominated  speaking  through  the  nose.     Such 
persons  generally  express  themselves  in  an  unnecessarily  loud  tone  ; 
they  speak  as  if  they  were  out  of  breath,  and  there  is  a  sort  of  whis- 
tling sound  in  the  speech,  as  if  the  air  was  sipped  in  through  the  mouth, 
and  then  blown  out  through  the  nose  ;  and  in  the  advanced  stage, 
particularly  if  the  disease  commenced  in  youth,  the  utterance  becomes 
indistinct.     Such  cases  are  generally  most  unfavorable,  and  I  make 
it  a  rule  to  inform  the  patient  or  his  friends  of  my  suspicions,  even 
before  I  institute  an  examination,  as  this  symptom  is  always  indica- 
tive of  long-continued  dulness  of  hearing.     If  the  patient  is  a  person 
of  intelligence  we  generally  find  that  he  anxiously  and  intently  watches 
the  motions  of  the  lips  of  the  person  by  whom  he  is  addressed,  in 
order  to  assist  him  in  making  out  what  is  said.     I  know  several  per- 
sons who  can  understand  what  is  addressed  to  them  by  their  friends, 
or  those  to  whom  they  are  accustomed,  simply  by  observing  the  mo- 
tions of  the  lips.     The   works  describing  the  mode  of  teaching  ar- 
ticulation to  the  deaf  and  dumb  may  be  read  with  advantage  on  the 
subject. 

Persons  with  "musical  ears"  have  remarked  to  me  that  they  first 
became  aware  of  the  approach  of  deafness  by  not  being  able  to  dis- 


90  TINNITUS     AURIUM. 

tinguisli  one  octave  from  another ;  yet  in  many  instances  the  musical 
ear  remains  unimpaired  though  general  hearing  is  much  affected. 

I  have  thus  described  the  routine  of  examination  that  will  be  found 
most  practically  useful.  Having  proceeded  thus  far,  we  may  inquire 
into  the  history  of  the  disease,  its  duration,  assigned  cause,  the  pain, 
noise,  the  probable  hereditary  nature  of  the  complaint,  &c.,  and  hear 
the  subjective  symptoms,  in  the  usual  manner  in  which  we  would  pro- 
ceed to  examine  any  other  medical  or  surgical  case.  There  are, 
however,  a  few  inquiries  which  should  be  particularly  made,  espe- 
cially as  to  the  existence  of  tinnitus  aurium  ;  and,  if  such  be  present, 
what  are  the  peculiar  characters  of  it ;  how  many  kinds  of  noises  are 
experienced;  whether  they  are  permanent  or  intermitting;  under 
what  circumstances  they  are  decreased  or  diminished ;  and,  above  all, 
whether  the  patient  refers  them  to  the  ears  or  to  the  interior  of  the 
head ;  and  whether  one  or  both  ears  are  equally  affected  by  them. 

The  value  of  tinnitus  as  a  diagnostic  has  been  greatly  overrated. 
It  is  certainly  one  of  the  most  distressing  as  well  as  the  most  fre- 
quent symptoms  attendant  upon  affections  of  the  organs  of  hearing, 
but  its  cause  is  very  obscure  and  dij0&cult  to  comprehend,  and  its 
removal  still  more  difficult  to  achieve.  I  know  no  symptom  concern- 
ing which  a  more  cautious  prognosis  should  be  given,  as  it  is  one 
common  to  almost  all,  and  peculiar  to  none,  of  the  diseases  of  the  ear. 
Like  muscse  volitantes  in  the  eye,  it  may  exist  as  an  isolated  symptom, 
or  it  may  be  an  attendant  upon  several  aural  diseases.  It  is  often 
caused  by  cerebral  disease  ;  therefore  we  should  carefully  inquire 
whether  it  is  felt  in  the  head  or  in  one  or  both  ears ;  it  is  sometimes 
an  accompaniment  of  derangement  of  the  circulating,  digestive,  or 
uterine  organs;  of  congestion  of  the  brain,  hemorrhage,  hypochon- 
dria, hysteria,  chlorosis,  anaemia,  typhus,  influenza,  or  simple  catarrh ; 
of  closure  of  the  external  meatus,  obstruction  of  the  Eustachian  tube, 
and  impaction  of  the  auditory  passage  Avith  wax;  a  foreign  body, 
or  even  a  hair  resting  on  the  tympanal  membrane,  as  well  as  engorge- 
ment of  the  lining  membrane,  or  mucous  collections  in  the  tympanal 
cavity,  and  also  nervous  deafness,  will  all  produce  it.  Furthermore, 
we  may  remove  the  original  disease,  give  a  healthy  action  to  the 
affected  organ,  and  restore  its  function, — yet  will  the  noise  remain. 
It  is  always  most  felt  at  night  when  the  patient  lies  down  to  rest ;  it 
is  least  experienced  in  the  open  air,  in  a  crowd,  or  when  travelling  in 
a  carriage.  It  seldom  or  never  co-exists  with  an  open  tympanal  mem- 
brane, and,  therefore,  perforation  of  the  drum  has  been  resorted  to. 


TINNITUS     A  U  R  I  U  M.  91 

and  occasionally  with  effect,  to  relieve  patients  of  this  distressing 
malady.  In  cases  of  complete  acquired  deaf-muteism  it  is  not  pre- 
sent. So  great  is  the  discomfort  which  it  gives,  that  persons  incurably 
deaf,  and  who  are  quite  conscious  of  the  impossibility  of  restoring 
their  hearing,  will  still  apply  to  be  relieved  from  this  haunting  and 
most  annoying  symptom;  and  therefore  it  is,  that,  in  the  quack  ad- 
vertisements, we  always  read  of  the  "promise  to  cure  ringings  and 
noises  in  the  ears."  The  peculiar  characters  of  the  tinnitus,  and  the 
noises  to  which  it  is  likened,  are  as  variable  as  sound  itself.  Do 
these  characters  depend  upon  the  cause  of  deafness,  or  the  portions 
of  the  organs  affected  ?  I  have  taken,  some  pains  to  investigate  the 
subject,  and  I  believe  not.  They  are  no  more  dependent  upon  the 
causes  of  the  disease,  nor  the  structm-es  engaged,  than  the  peculiar 
form  which  ocular  spectra  and  motes  floating  before  the  eyes  are  con- 
tingent upon  the  parts  concerned  in  ophthalmic  or  cerebral  diseases. 
No  one  has  yet  been  able  to  arrange  or  classify  the  peculiar  descrip- 
tion of  muscse  contingent  upon  congestion,  amaurosis,  choroid  disease, 
cataract,  or  disease  of  the  brain  or  its  membranes ;  no  more  than  they 
can  satisfactorily  account  for  both  muscse  and  "noises  in  the  ears"  in 
cases  of  hemorrhage. 

I  think  the  descriptions  which  patients  give  of  the  noise  which  they 
experience  depend,  to  a  certain  degree,  upon  their  fancy,  their  graphic 
powers  of  explanation,  and  not  unfrequently  upon  their  rank  of  life, 
or  the  position  in  which  they  have  been  placed,  and  the  sounds  with 
which  they  are  most  familiar :  thus,  persons  from  the  country  or  rural 
districts  draw  their  similitudes  from  the  objects  and  noises  by  which 
they  have  been  surrounded,  as  the  falling  and  rushing  of  water,  the 
singing  of  birds,  buzzing  of  bees,  and  the  waving  or  rustling  of  trees ; 
while,  on  the  other  hand,  persons  living  in  towns,  or  in  the  vicinity 
of  machinery  or  manufactures,  say  that  they  hear  the  rolling  of  car- 
riages, hammerings,  and  the  various  noises  caused  by  steam-engines. 
Servants  almost  invariably  add  to  their  other  complaints,  that  they 
suffer  from  "the  ringing  of  bells"  in  their  ears;  while  in  this  country, 
old  women  much  given  to  tea-drinking  sum  up  the  category  of  their 
ailments  by  saying,  that  "all  the  kettles  in  Ireland  are  boiling  in 
their  ears."  The  tidal  sound,  or  that  which  we  can  produce  by  hold- 
ing a  conch-shell  to  the  ear,  is,  however,  what  is  most  frequently 
complained  of.  Sometimes  the  tinnitus  exists  as  an  isolated  symptom ; 
but  in  several  such  cases  I  have  remarked,  that  sooner  or  later  either 
aural  or  cerebral  disease  manifested  itself.     Removing  the  cause  and 


92  CAUSESOFTINNITUS. 

curing  the  deafness  will  often,  but  not  always,  relieve  the  patient  of 
the  noise. 

The  causes  of  tinnitus — for  they  must  be  many — are  never  likely 
to  be  fully  explained ;  and  morbid  anatomy  holds  out  but  little  hope 
of  cleanng  up  the  mystery  attending  the  production  of  noises  in 
either  the  ears  or  head.  From  its  not  being  present  where  the  mem- 
brana  tympani  has  been  in  whole  or  in  part  removed,  and  that  hearing 
is  not  quite  destroyed,  and  from  its  cessation  after  artificial  perfora- 
tion on  the  one  hand ;  and,  as  we  have  all  experienced  its  occasional 
presence  in  influenza,  sore  throat,  or  simple  catarrh,  until  by  press- 
ing air  through  the  Eustachian  tube  into  the  tympanal  cavity,  we  in- 
stantaneously get  rid  of  it, — on  the  other;  I  am  firmly  of  opinion 
that  one  cause  of  tinnitus  is  a  non-vibratability  of  the  membrana 
tympani.  All  cases  of  closure  of  the  Eustachian  tube,  of  collapse 
of  the  membrana  tympani,  as  well  as,  in  most  instances,  of  accumu- 
lations in  the  middle  ear,  are  attended  by  this  symptom.  Kramer 
formerly  thought  that  his  so-called  nervous  deafness  might  be  divided 
into  the  erethetic,  or  that  attended  with  tinnitus — generally  incurable 
— and  the  torpid,  or  that  without  tinnitus,  said  to  be  relieved  by  fu- 
migation !  He  has,  however,  subsequently  relinquished  this  fanciful 
and  hypothetical  division.  Laennec  considered  tinnitus  as  an  acoustic 
illusion ;  but  buzzing  in  the  ear  might,  he  thought,  depend  on  spas- 
modic contraction  of  the  muscles  of  the  ossicles.  This  latter  theory, 
though  unsustained  by  any  fact,  serves  to  support  the  hypothesis  of 
the  want  of  vibrating  power  in  the  membrana  tympani  being  one 
cause  of  tinnitus;  possibly  a  similar  state  of  the  membrane  of  the 
fenestra  rotunda  may  be  another. 

Physicians  are  too  much  in  the  habit  of  treating  patients  for  this 
symptom  alone,  without  having  made  a  careful  examination  of  the 
ears.  I  have  seen  persons  who  had  been  subjected  to  a  severe  course 
of  treatment,  consisting  of  cupping  and  leeching,  low  diet,  blistering 
the  nape  of  the  neck,  purgation,  salivation,  or  the  administration  of 
blue  pill  and  James's  powder,  for  noises  in  the  ears'  and  head,  until 
it  was  eventually  discovered  that  all  their  symptoms  proceeded  from 
a  comparatively  thin  cake  of  hardened  wax  pressing  on  the  drum  of 
the  ear. 

Inquiries  as  to  the  general  health  of  the  patient,  the  due  perform- 
ance of  all  the  functions,  and  the  endeavor  to  ascertain  how  much  of 
the  disease  is  purely  local,  or  dependent  upon  some  constitutional 
affection,  will,  no   doubt,  be  made  by  every  educated  physician  or 


THE     APPLICATIOX     OF     REMEDIES LEECHING.  03 

surgeon,  so  that  it  is  unnecessary  here  to  call  special  attention  to  these 
circumstances. 

By  the  foregoing  method  of  examination  and  observation  of  the 
physical  signs,  and  an  attention  to  the  rules  which  I  have  endeavored 
to  lay  down,  we  ought  in  almost  every  case  be  able  to  form  a  tolera- 
bly accurate  diagnosis. 

As  much  ignorance  prevails  with  respect  to  the  mode  of  applying 
even  the  ordinary  remedies  employed  in  am-al  affections,  a  few  re- 
marks thereon  may  not  be  out  of  place,  before  entering  upon  a  de- 
scription of  the  cases  to  which  they  are  applicable.  As  most  of  the 
diseases  of  the  organs  of  hearing  are  originally  of  an  inflammatory 
■character,  depletion  is  strictly  enjoined;  I  have,  however,  seldom 
found  it  necessary  to  resort  to  general  bleeding ;  but  local  depletion 
is  imperatively  required,  either  by  cupping  or  by  leeches.  The 
former  method  is  not  easily  managed  so  near  the  part  affected  as  to 
be  of  much  service ;  but  in  cases  of  very  severe  otitis,  it  may  be  had 
recourse  to,  and  a  dexterous  cupper  will  with  a  small  instrument  take 
several  ounces  of  blood  from  the  soft  parts  immediately  behind  and 
beneath  the  mastoid  process ;  and  if  the  head  be  much  engaged, 
blood  may  also  be  abstracted  by  the  same  means  from  the  nape  of 
,the  neck.  Leeches  are,  however,  the  most  effectual  means  of  ab- 
stracting blood  and  relieving  pain  in  all  such  cases  ;  but  they  should 
not  be  applied  in  the  manner  heretofore  employed  behind  the  mastoid 
process  :  to  be  of  service  they  must  be  attached  with  a  small  bevil- 
mouthed  leech-glass  immediately  around  and  within  the  edge  of  the 
external  meatus,  in  the  fossa  behind  the  tragus,  and,  if  necessary,  in 
front  of  that  prominence,  in  the  hollow  formed  by  depressing  the 
jaw.  From  four  to  six  leeches  may  be  readily  attached  round  the 
meatus,  and  in  this  situation  they  will  produce  more  immediate  and 
permanent  relief  than  three  times  the  number  affixed  behind  the 
auricle.  The  application  in  front  of  the  tragus  is  also  very  much 
more  effectual  than  upon  the  mastoid  region.  When,  however,  the 
latter  locality  becomes  itself  the  seat  of  inflammatory  action,  they 
should  also  be  applied  freely  all  over  it.  Where  we  have  already  re- 
cently applied  leeches  in  the  two  first-mentioned  places,  and  the  parts 
have  thereby  become  swollen  and  irritated,  the  next  most  advanta- 
geous position  is  beneath  the  lobe  of  the  auricle,  behind  the  ramus 
of  the  jaw.  I  do  not  know  any  painful  affection  in  which  leeches 
applied  in  the  manner  directed  produce  the  same  amount  of  imme- 
diate relief,  as  in  disease  of  the  ear.     They  should  be  had  recourse 


94  LEECHING. 

to  again  and  again,  even  upon  the  same  day,  and  applied  in  numbers, 
to  relieve  paroxysms  of  pain,  as  well  as  to  lessen  the  degree  of  red- 
ness and  vascularity  observable  in  the  inflamed  parts. 

Unless  in  cases  of  violent  otitis,  heretofore  leeches  were  seldom  used 
to  relieve  aural  diseases,  because  the  practitioner,  not  being  acquainted 
with  the  nature  or  seat  of  the  majority  of  these  aifections,  and  not 
possessing  the  means  or  knowledge  capable  of  effecting  a  proper 
inspection  of  the  parts  engaged,  seldom  made  an  accurate  diagnosis. 
He  worked  in  the  dark,  and  prescribed  at  random,  more  frequently 
than  when  treating  any  other  class  of  diseases,  no  matter  how  obscure ; 
and  hence  the  opprobrious  epithets  which  the  public,  and  even  many 
of  the  profession,  applied  to  the  treatment  of  diseases  of  the  ear. 
Such  observations  were,  however,  just  as  applicable  to  the  treatment 
of  diseases  of  the  uterus  and  vagina  until  the  introduction  of  the 
speculum  into  modern  practice.  As  the  space  to  which  leeches  can 
be  applied  is  limited,  and  as  it  is  often  a  tedious  and  troublesome 
operation,  it  requires  some  care  and  dexterity  in  its  management.  I 
generally  mark  the  places  where  they  may  be  applied  with  spots  of 
ink,  in  order  that  the  apothecary  may  not  make  any  mistake ;  for,  if 
this  is  not  done,  we  sometimes  find  that  the  leeches  have  been  allowed 
to  attach  themselves  to  the  cavity  of  the  concha,  or  other  places  on 
the  auricle,  where  they  are  of  no  use,  and  often  give  rise  to  much 
irritation,  oedema,  and  even  erysipelas.  The  external  meatus  should 
first  be  filled  with  a  bit  of  cotton  wool,  to  a  level  with  the  external 
aperture,  not  so  much  for  the  purpose  of  preventing  the  leeches  going 
in  too  far,  as  to  exclude  the  blood,  which  is  very  likely  to  flow  back 
and  accumulate  at  the  bottom  of  the  meatus  auditorius  externus, 
coagulating  and  crusting  over  the  surface  of  the  tympanal  membrane, 
thereby  causing  much  annoyance  to  the  patient,  and  even  an  aggra- 
vation of  his  symptoms.  The  posterior  lip  of  the  external  aperture 
affords  the  largest  and  most  convenient  surface  for  the  application  of 
leeches,  and  in  an  adult,  three  may  always  be  attached  thereto  with 
facility.  The  anterior  lip,  being  more  concealed  and  slightly  con- 
cave, cannot  so  Avell  be  got  at,  yet  two  may  generally  be  applied 
there.  The  next  best  part  to  which  to  apply  them  is  the  depression 
in  front  of  the  tragus,  immediately  below  the  inferior  root  of  the 
zygoma,  where  in  aural  inflammations  the  patient  is  so  frequently 
susceptible  of  pain  upon  the  least  pressure,  and  there,  six  or  eight 
may  be  applied  if  necessary. 

As  leech-bites  on  any  of  those  places  which  I  have  mentioned  con- 


COUNTER-IRRITATION.  95 

tinue  to  bleed  freely  for  a  long  time,  the  person  employed  to  apply 
the  leeches  should  be  directed  to  stop  them  as  soon  as  the  proper 
quantity  of  blood  has  been  removed,  either  by  the  application  of  lunar 
caustic,  or  any  of  the  most  approved  means  for  this  purpose ;  but  it 
is  necessary  that  we  should  be  aware  of  the  fact,  that  the  hemorrhage 
from  leech-bites  on  these  parts  is  more  likely  to  continue  than  elsewhere. 
The  leech-bites  do  not  cause  extravasation  and  blackening  of  the  au- 
ricle as  they  so  frequently  do  the  parts  about  the  eye  ;  but  they  often 
give  rise  to  erysipelatous  inflammation,  and  therefore  in  all  such  cases 
the  idiosyncrasy  of  the  patient  in  this  matter  should  be  previously 
inquired  into.  I  know  a  gentleman  with  a  remarkably  dry  skin,  who 
labors  under  chronic  inflammation  of  the  membrana  tympani  and  the 
mucous  lining  of  the  middle  ear,  who  is  so  susceptible  in  this  respect 
that  the  application  of  a  single  leech  will  invariably  produce  erysi- 
pelas of  the  side  of  the  head  and  face.  The  cotton  with  which  the 
auditory  passage  is  stuffed,  and  the  external  portion  of  which  always 
becomes  saturated  with  blood,  should  not  be  removed  until  the  oozing 
from  the  leech-bites  has  quite  ceased. 

With  respect  to  counter-irritation : — in  acute  cases,  common  fly 
blisters  are  the  most  convenient  and  effectual  method ;  but  as  the 
space  uncovered  by  hair  over  which  they  can  be  applied  behind  the 
auricle  is  limited,  they  should  not  have  the  usual  adhesive  margin  on 
the  inner  concave  edge,  and  they  should  be  spread  on  fine  leather, 
that  they  may  fit  closely  over  the  irregular  surface  to  which  they  are 
applied.^     If  it  is  desirable  to  keep  the  blister  open,  or  to  establish 

'  [I  cannot  here  too  strongly  recommend  the  substitution  of  the  Cantharidal  Collodion, 
as  proposed  by  C.  S.  Rand,  Pharmaceutist,  of  Philadelphia,  for  the  ordinary  bhstering 
ointment.  The  Cantharidal  Collodion  was  first  proposed  as  a  vesicant  by  Hisch,  a  Rus- 
sian chemist,  in  1849.  He.  however,  used  a  much  larger  quantity  of  the  canlharides 
than  was  necessary.  Mr.  Rand's  process  is  to  treat  by  displacement,  half  a  pound  of 
bruised  cantharides  (which  is  half  the  quantity  proposed  by  Hisch),  with  one  pound  of 
sulphuric  and  three  ounces  of  acetic  ether.  In  two  ounces  of  this  saturated  ethereal 
tincture,  dissolve  twenty-five  grains  of  cotton  powder  ("  gun  cotton  '').  Mr.  R.  proposes 
to  overcome  the  usual  contractile  property  of  the  collodion  by  adding  one  per  cent,  of 
Venice  turpentine,  which  is  a  great  improvement  on  Hisch's  plan.  We  have  thus  a  con- 
venient blistering  liquid  which  can  be  applied  to  the  mastoid,  or  any  surface,  no  matter 
how  irregular,  with  the  greatest  facility,  by  means  of  a  camel's  hair  pencil.  A  single 
layer  of  this,  well  applied,  will  (according  to  my  own  experience)  blister  in  a  shorter 
time,  and  more  effectually,  than  the  best  prepared  ointment,  and  we  have  the  security 
of  no  other  part  getting  blistered  than  that  which  we  desire,  as  often  happens  by  a  blis- 
ter plaster  sliding.  When  it  is  desirable  to  produce  a  rapid  effect,  there  is  only  need  to 
cover  the  surface,  immediately  after  the  application  is  made,  by  a  piece  of  oil-silk,  to  pre- 
vent rapid  evaporation. — A.  H.] 


96  LINIMENTS,     FOMENTATIONS,     DROPS,     ETC. 

an  issue,  it  can  easily  be  effected  by  removing  the  cuticle  and  dressing 
the  raw  surface  with  Albespeyrre's  plaster,  the  most  convenient  spot 
for  which  is  immediately  behind  the  lobe,  and  beneath  the  mastoid 
protuberance.  It  is,  however,  especially  in  the  male  sex,  difficult  to 
retain  such  means  in  that  locality  without  a  bandage. 

In  old  chronic  cases,  where  the  disease  is  of  long  standing,  and 
there  is  much  thickening  of  the  membrana  tympani,  I  have  found  that 
the  pustulation  produced  by  the  application  of  tartar  emetic  ointment 
is  the  most  effectual  method.  A  small  quantity  of  the  ointment 
should  be  rubbed  once  or  twice  a  day  to  all  that  part  of  the  mastoid 
region  which  is  not  covered  by  hair, — care  being  taken  not  to  let  the 
ointment  spread  over  the  back  of  the  auricle,  where  it  would  produce 
very  angry  and  irritable  sores, — until  a  copious  eruption  is  produced. 
A  bit  of  soft  linen  should  be  applied  between  the  auricle  and  the  sur- 
face submitted  to  the  action  of  the  remedy.  As  soon  as  the  pustules 
are  fully  developed  the  application  should  be  discontinued,  and  the 
part  allowed  to  heal  perfectly  before  it  is  resumed.  To  be  effectual, 
however, 4his  remedy  must  be  continued  for  several  weeks,  or  even 
months.  As  it  is  not  always  possible  to  measure  or  control  its  action, 
a  poultice  should  be  applied  occasionally  when  the  pustules  spread,  or 
seem  inclined  to  coalesce. 

The  usual  rubefacient  and  vesicating  liniments  must  be  used  with 
caution  when  applied  to  the  mastoid  region,  as  their  action  is  very  apt 
to  spread  over  the  back  of  the  auricle,  and  cause  considerable  swell- 
ing and  irritation  thereof.  I  have  on  several  occasions  seen  the  erup- 
tion caused  by  croton  oil  extend  from  the  mastoid  region  not  only  over 
the  external  ear,  but  to  the  side  of  the  face,  and  produce  oedema,  red- 
ness, and  intense  itching  of  the  eyelids.  Where  there  is  much  neu- 
ralgic pain  complained  of,  extending  from  the  ear  over  the  side  and 
back  of  the  head,  I  have  found  the  compound  camphor  liniment,  with 
extract  of  belladonna,  one  of  the  most  useful  applications ;  but  in 
this  preparation,  care  should  be  taken  to  rub  the  belladonna  first  with 
a  little  water  in  a  mortar,  otherwise  it  will  not  mix  with  the  liniment. 
In  children  and  young  persons  the  strong  tincture  of  iodine,  contain- 
ing some  iodide  of  potassium,  is  a  very  useful  remedy,  and  probably 
acts  specifically  as  well  as  a  stimulant ;  it  should  be  applied  with  a 
camel-hair  pencil  daily,  or  every  second  day,  unless  the  part  begin  to 
vesicate  or  the  cuticle  to  peel  off,  when  the  application  should  be  dis- 
continued for  a  few  days.  The  use  of  iodine,  however,  by  the  endermic 
method  is  only  of  value  by  being  long  persisted  in.     Indeed  the  same 


GALVANISM     AND     ELECTRICITY.  97 

may  be  said  of  most  irritants, — to  be  effective  they  must  be  continued 
for  a  great  length  of  time,  long  before  the  expiration  of  wbicb, 
in  many  cases,  both  the  patient  and  the  practitioner  are  tired  of  each 
other. 

The  application  of  heat  and  moistm-e  is  particularly  grateful; 
steaming  the  ear  by  holding  it  over  the  vapor  of  some  very  hot 
"water  placed  at  the  bottom  of  a  long,  narrow  vessel,  medicated  with 
hyoscyamus,  opium,  belladonna,  or  with  the  ordinary  decoction  of 
marsh-mallows,  camomile,  or  poppy-heads,  gives  great  comfort.  The 
Russians  employ  a  peculiar  apparatus  for  relieving  pain  in  the  ear, 
consisting  of  a  funnel-shaped  roll  of  linen,  the  small  end  of  which  is 
applied  to  the  meatus,  while  the  large  end,  in  which  various  balsamic 
substances  are  placed  and  set  fire  to,  is  allowed  to  burn  down  slowly 
like  a  moxa.  A  warm  linseed-meal  poultice,  renewed  every  two  or 
three  hours,  gives  great  relief.  Stupes  and  fomentations  are  not  as 
efficacious  in  aural  as  in  ophthalmic  inflammations. 

Under  no  circumstances  should  we  pour  any  stimulating  or  sedative 
liquors  into  the  ear.  From  the  frequency  of  this  most  unjustifiable 
practice  in  this  country,  I  feel  I  cannot  too  strongly  deprecate  it. 
If  there  is  one  substance  more  irritating  than  another  in  the  Pharma- 
copoeia, it  is  poured,  secundum  artem,  into  the  ear,  to  relieve  pain, 
or  cure  deafness,  to  lessen  or  to  increase  the  secretion  of  wax  !  This 
practice  is  often  the  cause  of  myringitis.  Why  are  not  these  essen- 
tial oils,  stimulating  liniments,  this  turpentine,  creasote,  tincture  of 
cantharides,  oil  of  origanum,  &c.,  poured  into  the  eye,  or  injected 
into  the  urethra,  in  cases  of  inflammation  of  these  parts  ?  Why  do 
not  surgeons  prescribe  a  roasted  onion,  or  a  boiled  fig,  for  inflamma- 
tions of  other  parts  as  well  as  the  ear  ? 

I  have  no  faith  in  either  electro-magnetism,  galvanism,  or  electri- 
city, in  relieving  deafness.  I  never  knew  a  case  which  had  proved 
unamenable  to  other  treatment  cured  by  any  of  these  means.  True 
it  is  we  read  in  the  periodicals  from  year  to  year  of  cures  effected  by 
such  agents,  but  for  the  most  part  they  are  unauthenticated,  and  in 
all,  there  is  in  the  description  of  symptoms  and  the  diagnosis  a  mani- 
fest want  of  knowledge  on  the  subject  of  aural  medicine  and  surgery. 
How  would  the  profession  receive  an  account  of  a  "  cure  of  blindness 
by  electro-galvanism,"  without  being  informed  what  had  been  the 
cause  of  such  loss  of  sight  ?  However,  as  I  believe  the  great  mass 
of  aural  diseases  are  the  products  of  inflammation  in  some  form  or 
other,  it  is  obvious  that  such  agents  can  effect  little  for  their  removal. 

7 


98  MERCURY. 

Even  supposing  the  auditory  nerve  to  be  the  seat  of  the  disease,  and 
that  a  true  cophosis,  the  analogue  to  amaurosis,  is  present,  it  may  be 
asked,  how  few  uncomplicated  cases  of  the  latter,  of  simple  func- 
tional impairment  or  insensibility  of  the  retina  or  optic  nerve,  with- 
out any  cerebral  lesion,  do  we  meet  with  ?  and  how  still  fewer  do  we 
remember  being  cured  or  relieved  by  electricity  or  galvanism  ?  It  is 
therefore  unnecessary  to  describe  the  various  ingenious  machines 
which  have  been  invented,  and  are  described  in  books,  for  applying 
these  means  to  the  Eustachian  tube,  and  the  external  surface  of  the 
tympanal  membrane. 

Mercury  is  the  medicine  which  of  all  others  acts  most  beneficially 
in  diseases  of  the  ears,  simply  on  account  of  its  specific  efficacy  in 
arresting  or  controlling  inflammation  or  removing  its  products.  But 
as  there  are  a  variety  of  aural  affections  to  which  it  is  applicable,  so 
are  there  a  variety  of  modes  of  administering  this  powerful  mineral, 
and  a  diversity  of  preparations,  each  specially  apposite  to  the  parti- 
cular stage  of  disease,  the  class  of  symptoms,  or  the  peculiar  habits 
and  constitution  of  the  patient.  A  well-educated  surgeon,  expe- 
rienced in  the  administration  of  mercury,  and  with  general  and  en- 
larged views  both  as  to  the  action  of  medicine  and  disease,  will,  no 
doubt,  suit  the  remedy  to  the  particular  case ;  but  as  a  rule  I  may 
remark,  that  the  modes  of  exhibiting  it  in  ocular  affections  will  serve 
as  a  safe  guide  for  giving  it  in  diseases  of  the  organ  of  hearing.  In 
the  more  violent  inflammations  of  the  fibrous  structure  of  the  mem- 
brana  tympani,  the  periosteal  lining  of  the  cavity  of  the  tympanum, 
the  Eustachian  tube,  or  the  deeper  portion  of  the  external  meatus, 
and  also  the  inflammations  of  the  internal  ear,  when  such  can  be 
diagnosed,  as  well  as  the  specific  inflammations  of  a  rheumatic  or 
syphilitic  character,  where  actual  ptyalism  is  indicated,  we  must  in- 
troduce it  quickly,  and  in  such  doses  as  will  bring  the  system  under 
its  influence  at  once,  just  as  we  would  in  inflammations  of  analogous 
tissues  in  the  eye,  the  envelopes  of  bones,  or  the  membranes  invest- 
ing the  joints  or  any  of  the  great  cavities  of  the  body.  In  such 
cases  small  and  frequently  repeated  doses  of  blue  pill  and  calomel, 
with  opium,  will  most  speedily  produce  the  desired  effect,  provided 
the  well-known  rules  for  the  administration  of  mercury  are  attended 
to.  I  do  not  think,  however,  that  students  attend  sufficiently  to  the 
symptoms  and  appearances  produced  by  mercury  on  the  mouth. 
Among  the  lower  orders,  or  with  hospital  patients,  the  over-action  of 
mercury  upon  his  patient  seldom  gives  the  practitioner  much  uneasi- 


MERCURY.  99 

ness ;  but  in  private  practice  it  is  very  different.  There  is  a  general 
horror  of  mercury  among  the  middle  and  upper  ranks ;  and  the  pre- 
judices and  superstitions  which  exist  on  the  subject,  with  respect  to 
the  mischief  it  does  to  the  constitution,  and  the  difficulty  of  "  getting 
it  out  of  the  bones,"  are  still  as  rife  among  some  classes  as  when  a 
distinguished  and  titled  senator  swore,  at  the  trial  of  St.  John  Long, 
that  he  saw  the  mercury  which  had  been  taken  many  years  before 
appear  in  globules  of  pure  quicksilver  upon  the  forehead  of  a  noble- 
man, drawn  forth  by  the  efficacy  of  the  sponge  and  liniment  of  the 
redoubted  curer  of  consumption !  The  effect  of  mercury  upon  the 
constitution,  as  well  as  upon  disease,  is  most  variable.  With  some 
the  slightest  quantity  will,  unless  carefully  watched,  produce  saliva- 
tion ;  while  other  persons  seem  totally  unsusceptible  of  its  influence. 
The  abuse,  however,  which  one  comes  in  for  in  practice,  because  a 
patient  has  suddenly  got  a  very  sore  mouth,  should  be  borne  with 
philosophic  indifference ;  as  although  the  effect  is  in  excess,  the 
desired  result  has  been  obtained.  Some  ladies,  however,  will  fret 
about  the  damage  likely  to  be  done  to  their  teeth,  more  than  they 
did  for  the  disease  for  which  the  mercury  was  given ;  and  many 
patients,  who  greedily  learn  all  the  symptoms  of  its  action,  will  com- 
plain of  sore  mouths,  spongy  gums,  aching  teeth,  &c.,  when,  in 
reality,  it  is  impossible  to  affect  them. 

Few  of  us  now  witness  what  mercmy  can  do  when  allowed  its  full 
swing,  or  when  pressed  to  the  extent  which  it  was  some  twenty  or 
thirty  years  ago.  Very  few  of  us  have  now  an  opportunity,  I  am 
happy  to  say,  of  witnessing  many  cases  of  mercurial  erythema,  or 
the  prostration  of  erythismus,  or  seeing  every  tooth  in  a  patient's 
head  shaking,  and  streams  of  saliva  pouring  from  his  mouth,  from 
the  long-continued  use  of  the  mineral, — when  the  wards  of  an  hos- 
pital were,  from  the  quantity  of  mercury  used,  both  internally  and 
externally,  by  pill-taking,  skin-rubbing,  plasters,  and  fumigation, 
rendered  mercurial  baths,  in  which  the  vapor  of  fetid  breaths  con- 
tended with  the  stench  of  sloughing  ulcers,  and  the  effluvia  resulting 
from  mercurial  diarrhoea.  Such  times  and  scenes  have  passed,  and  the 
public  and  the  profession  have  reason  to  rejoice  thereat.  Practitioners 
are  now  satisfied  with  the  mild  exhibition  of  mercury,  and  deem  it  more 
prudent  to  keep  up  a  gentle  action  for  some  time  than  to  allow  pro- 
fuse salivation  to  occur.  Yet,  notwithstanding  all  this,  cases  will 
happen  the  reverse  of  the  unsusceptible,  in  which  the  mineral  acts 
suddenly  and  violently,  and  its  effects  are  scarcely  within  control. 


100  MERCURY. 

This  will  occur  occasionally  in  peculiar  constitutions,  where  there  is 
a  special  idiosyncrasy.  Profuse  salivation  rapidly  sets  in,  the  glands 
of  the  neck  enlarge,  the  mucous  membrane  of  the  throat  and  inside 
of  the  mouth  runs  rapidly  into  ulceration,  and  the  tongue  swells  to 
an  alarming  extent,  so  as  to  resemble  a  case  of  glossitis,  but  it  is 
white,  slimy,  and  looks  like  a  piece  of  macerated  liver,  and  it  not 
uncommonly  protrudes  between  the  teeth.  The  most  alarming  symp- 
toms occasionally  follow,  and  in  one  instance  death  occurred,  in  this 
city,  some  years  ago,  from  swelling  of  the  tongue  in  the  manner 
which  I  described,  and  is  the  result  of  sudden  and  uncontrollable 
mercurial  action.  Sometimes  the  cheeks  and  other  parts  of  the  face 
swell  to  a  great  extent.  It  is  scarcely  necessary  to  state,  that  deglu- 
tition and  respiration  must  be  considerably  impaired  under  such  a 
state  of  things.  Among  the  remarkable  effects  of  mercury  which  I 
have  seen,  I  may  mention  the  instance  of  a  lady  who  once  consulted 
me  on  account  of  profuse  salivation  which  had  continued  for  five 
years. 

Now  it  as,  as  I  already  observed,  because  I  do  not  think  students 
attend  sufficiently  to  the  appearances  which  mercury  presents  in  the 
mouth,  and  also  because  cases  of  excessive  mercurial  action  must 
occasionally  occur  in  large  public  institutions,  where  it  is  absolutely 
necessary  to  give  mercury  to  external  patients,  many  of  whom  are 
either  careless  and  indifferent  about  themselves,  or  are,  from  their 
domestic  circumstances,  more  than  ordinarily  exposed  to  the  vicissi- 
tudes of  the  weather,  that  I  wish  particularly  to  draw  attention  to 
the  earlier  and  milder  symptoms  of  mercurial  action.  The  fetor  of 
the  breath  is  a  variable  sign,  although  when  present  it  is  an  unfailing 
indication :  but  it  is  seldom  commensurate  with  the  amount  of  mercu- 
rial action.  Sometimes  the  breath  is  naturally  heavy,  or  even  fetid, 
and  then  it  is  difficult  to  distinguish  the  one  from  the  other.  There 
is  a  peculiar  heavy  breath  belonging  to  strumous  patients,  which  it 
is  difficult  to  describe,  but  which,  once  perceived,  is  easily  recognised 
ever  after.  I  may  here  mention,  that  I  do  not  remember  a  single 
instance  in  which,  for  any  cause,  mercurial  action  was  fully  produced 
in  a  person  possessing  naturally  what  is  termed  "bad  breath,"  that 
that  most  unpleasant  affection  was  not  removed  by  it.  There  is  often 
some  swelling  of  the  gum  behind  the  last  molar  tooth  of  the  lower 
jaw ;  this  I  look  upon  as  an  almost  invariable  symptom,  and  some- 
times it  is  the  only  one  which  can  be  produced.  The  mucous  mem- 
brane between  the  tooth  and  the  angle  of  the  jaw  swells  and  overlaps 


MERCURY.  101 

the  tooth,  rendering  mastication  very  unpleasant,  and  giving  rise  to 
the  disagreeable  feeling  which  one  experiences  when  cutting  a  wise 
tooth.  We  should  always  look  into  the  mouth,  as  well  as  examine 
the  gums  beneath  the  front  teeth,  or  smell  the  breath,  where  we  wish 
to  assure  ourselves  as  to  the  progress  of  the  medicine.  Another 
early  symptom  is,  a  slight  discoloration  of  the  mucous  membrane 
upon  the  inside  of  the  cheeks :  it  loses  its  fresh,  red  color,  and  be- 
comes whitish,  particularly  opposite  the  crowns  of  the  lower  teeth, 
the  indentures  of  which  soon  manifest  themselves  upon  it,  and  in  a 
short  time,  if  the  medicine  be  not  lessened,  ulceration  will  ensue  in 
that  locality.  One  of  the  first  places,  however,  where  any  breach  of 
surface  occurs  upon  the  mucous  membrane  is  immediately  below  the 
red  border  of  the  under  lip,  opposite  the  junction  of  the  gum  with 
the  lower  incisors.  About  the  same  time  the  tongue  becomes  slightly 
swollen,  and  its  edge  deeply  indented  with  the  lower  front  teeth ;  it 
is  of  a  grayish-white  color,  and  covered  with  slimy  saKva.  All  the 
glandular  apparatus  within  the  mouth  is  then  excited  to  excessive 
action ;  the  papillre  of  the  sublingual  ducts  become  swollen  and  erect, 
and  the  ulcerations  upon  the  inside  of  the  lower  lip  and  opposite  the 
buccal  glands  upon  the  cheeks  present  the  appearance  of  aphthous 
sores,  grayish  in  the  centre,  with  a  light  straw-colored  margin ;  and 
saliva,  mixed  with  mucus,  pours  from  every  possible  outlet.  As, 
however,  these  observations  are  not  intended  as  a  dissertation  on  the 
pharmaceutical  preparations  or  therapeutic  effects  of  mercury,  but 
are  here  put  forward  in  order  to  explain  its  applicability  to  certain 
diseases  of  the  ear,  it  would  be  out  of  place  to  enter  into  an  exposi- 
tion of  the  means  best  calculated  to  correct  its  illegitimate  action 
either  upon  the  mouth  or  gastro-intestinal  membrane. 

In  the  more  chronic  or  subacute  forms  of  aural  disease — often 
where  the  mucous  membrane  is  extensively  engaged,  or  when  con- 
gestion, more  than  inflammation,  is  present — mercury  is  a  valuable 
remedy,  either  as  an  alterative  or  to  keep  up  sustained  but  gentle 
action  on  the  mouth ;  and  in  such  cases  the  milder  preparations,  such 
as  the  hydrargyrum  cum  creta,  in  combination  with  cicuta,  will  be 
found  advantageous. 

The  third,  and  perhaps  the  most  eiScacious  form,  in  which  mercury 
may  be  used,  is  that  of  the  bichloride,  still  commonly  known  in  this 
country  as  the  oxymuriate,  one  of  the  most  valuable  medicines  of  the 
entire  Pharmacopoeia.  A  treatise  might  be  written  on  the  virtues  of 
this  remedy,  and  the  vast  field  of  disease  over  which  it  exercises  a 


102  MERCURY. 

sanative  influence.  Combined  with  Peruvian  bark — which  the  che- 
mists say  is  incompatible,  but  the  product  of  the  decomposition  said 
to  be  produced  by  which,  may  be  the  very  substance  which  acts  most 
beneficially — it  is  almost  a  panacea  for  most  of  the  strumous  inflam- 
mations in  children  and  young  people;  and  its  power  in  controlling 
scrofulous  ophthalmia,  corneitis,  and  iritis,  &c.,  extends  equally  to 
the  cure  of  kindred  affections  in  the  ear.  It  is  the  best  remedy  I 
know  of  for  inducing  absorption  of  lymphy  deposits  in  the  membrana 
tympani,  and  general  thickening  and  opacity  of  that  structure,  as 
well  as  very  old  cases  of  chronic  inflammation  of  the  membrane  of 
the  cavitas  tympani.  It  is,  moreover,  when  properly  administered, 
one  of  the  safest  as  well  as  the  surest  preparations  of  mercury :  it 
may  be  taken  for  a  great  length  of  time ;  it  seldom  interferes  with 
the  ordinary  occupations  or  amusements  of  the  individual ;  it  leaves 
no  ill  efiects ;  it  rarely  induces  ptyalism ;  and  patients  improve  in 
health,  and  absolutely  grow  fat  while  using  it.^  It  may  be  given 
alone,  either  in  pill  or  dissolved  in  nitrous  ether,  proof  spirits,  or 
some  of  the  tinctures,  such  as  cascarilla,  but  it  is  much  more  soluble 
in  distilled  water  than  is  generally  known ;  it  may  be  combined  with 
the  muriated  tincture  of  iron  with  good  effect,  or  with  some  of  the 
preparations  of  sarsaparilla ;  but  bark — either  the  tincture,  syrup,  or 
decoction — is  of  all  others  the  medicine  best  suited  for  its  adminis- 
tration. Our  Dublin  preparation  of  the  syrup  is,  particularly  for 
children,  a  good  vehicle  for  it,  provided  the  mineral  is  first  dissolved 
in  a  little  distilled  water.  Oxymuriate  of  mercury  and  bark  some- 
times disagree,  producing,  shortly  after  being  taken,  pain  in  the 
stomach,  tenesmus,  griping,  and  even  diarrhoea;  in  such  cases  it  will 
generally  be  found  that  it  was  taken  before  breakfast  or  on  an  empty 
stomach ;  it  should  therefore  be  administered  an  hour  or  two  after 
meals.  But  when  it  disagrees,  even  with  such  precautions,  a  separa- 
tion of  the  constituents  will  obviate  the  unpleasant  effects :  thus  the 
mercury  may  be  taken  an  hour  or  two  before  or  after  the  bark.  From 
the  sixteenth  to  the  eighteenth,  or  even  a  quarter  of  a  grain,  may  be 
taken  three  times  a  day,  according  to  the  circumstances  of  the  case, 
for  weeks  and  even  months  together,  with,  however,  short  intervals 
occasionally. 

Deafness  has  been  attributed  to  the  over-use  and  abuse  of  mercury, 
and  I  was  myself  once  under  the  impression  that  such  might  happen, 

'  I  understand  that  the  bichloride  of  mercury,  in  large  doses,  is  used  to  fatten  and 
improve  the  condition  of  horses  in  the  West  Indies. 


MEECURY.  103 

from  having  seen  some  cases  of  almost  complete  loss  of  hearing  in 
persons  who,  it  was  stated,  had  taken  large  quantities  of  mercury  for 
a  long  time.  I  have  recently  made  particular  inquiry  after  these 
cases,  and  I  have  carefully  examined  the  membrana  tympani  in  each, 
and  in  every  case  I  found  it  thickened,  opaque,  and  manifesting  all 
the  appearances  consequent  upon  deposits  between  its  layers, — the 
result,  no  doubt,  of  specific  inflammation.  Each  of  these  cases  were 
originally  syphilitic,  and  exhibited  evident  traces  of  a  scrofulous  taint, 
and  they  all  acknowledged  that  they  had  taken  the  mercm-y  most 
irregularly,  and  had  been  for  years  affected  with  secondary  symptoms. 
I  think  it  yet  remains  to  be  proved  that  mercury  produces  inflamma- 
tion of  either  the  eyes  or  ears.  Practitioners  of  the  present  day 
have  received,  as  by  a  sort  of  hereditary  tradition,  and  still  entertain 
the  idea  that  mercury  will  produce  iritis ;  and  the  homoeopaths  flour- 
ish the  assertion  whenever  and  wherever  an  opportunity  offers,  as  a 
proof  of  the  grand  principle  of  their  doctrine.  Is  it  a  fact  that 
mercury  taken  for  the  cure  of  other  diseases  than  those  which  will 
of  themselves  induce  inflammation  of  the  iris,  the  sclerotic,  or  choroid, 
— such  as  syphilis,  rheumatism,  gout,  or  scrofula, — has  ever  caused 
the  train  of  symptoms  of  internal  inflammation  of  the  eye  generally 
known  as  iritis? 

The  preparations  of  iodine  and  potassium  may  be  employed  in 
aural  affections,  and  will  be  found  efficacious  just  as  they  act  on  the 
general  health  or  the  diseases  of  other  organs;  so  likewise  with 
cod-liver  oil.  The  only  medicine  I  know  of  which  appears  to  exercise 
an  influence  upon  tinnitus  aurium  is  leopard's  bane,  the  arnica  mon- 
tana,  formerly  much  in  use  for  rheumatic  affections,  and  as  an  ex- 
ternal application  in  sprains  and  bruises.  The  value  of  this  and  other 
remedies  in  diseases  of  the  ear,  as  well  as  their  mode  of  administra- 
tion or  application,  will  be  explained  when  speaking  of  the  diseases 
to  which  they  are  applicable. 


104 


CHAPTER    III. 

i.        STATISTICS   AND   NOSOLOGY   OF   EAR   DISEASES. 

Statistics  of  St.  Mark's  Hospital. — Analogy  between  Diseases  of  the  Eye  and  Ear ; 
Amaurosis  and  Nervous  Deafness. — The  Author's  Table  of  2385  Cases:  their  Diseases, 
Ages,  and  Sexes. — Kramer's  Statistics,  their  Value  and  Peculiarities. — Tscharner's 
Statistics. — Toynbee's  Pathological  Investigations. — The  Author's  Abstract  of  200  Cases. 
— Proofs  of  Inflammatory  Action  in  Ear  Diseases. — Nosological  Arrangements  of  Galen, 
Buchanan,  Harvey,  Deleau,  Kramer,  Pilcher,  Lincke,  &c. — The  Anatomical  and  Patho- 
logical Basis. — The  Author's  Classification. 

The  subject  of  vital  statistics  has  of  late  years  engaged  the  at- 
tention of  the  scientific  world  more  than  at  any  former  period,  and 
■within  the  last  few  years  the  statistics  of  ear  diseases  have  been 
noticed  by  a  few  Continental  writers.  As,  however,  some  time  must 
elapse  before  an  exact  knowledge  of  aural  diseases  is  arrived  at,  and 
until  their  nomenclature  is  fixed,  such  variety  must  exist  in  the  ac- 
counts of  different  authors  as  to  lead  to  apparent  discrepancy,  if  not 
to  a  semblance  of  ignorance.  It  is  not  as  in  general  medicine  or 
surgery,  where  there  is  but  little  danger  among  educated  practitioners 
of  mistakes  in  registering  cases  of  fever,  pneumonia,  peritonitis,  or 
calculus ;  in  diseases  of  the  ear,  what  one  practitioner  would  call  ner- 
vous deafness,  another  might  believe  to  be  the  result  of  some  organic 
lesion  consequent  upon  inflammation,  &c. ;  and  so  the  proportion 
which  the  different  diseases  bear  to  one  another  or  the  whole  would 
vary  according  to  the  mode  of  registering,  and  the  amount  of  know- 
ledge and  peculiar  opinions  of  the  registrar.  As  therefore  statistics 
involve  nomenclature,  so  does  the  latter  subject  lead  us  to  the  con- 
sideration of  nosological  arrangement. 

The  earliest  and  most  complete  statistics  of  ear  diseases  published 
in  these  Kingdoms  were,  I  believe,  those  appended  to  the  Report  of 
St.  Mark's  Hospital  for  the  year  1844-45.  Since  that  period  as  ac- 
curate a  registry  has  been  kept  of  all  the  cases  which  presented  as 
the  means  and  appliances  at  any  public  institution  can  afford,  and  the 


STATISTICS    OF    THE    EAR.  105 

results  thereof  have  appeared  from  time  to  time  either  in  the  Annual 
Reports  or  in  the  public  journals.  I  do  not  think  it  possible  to  keep 
a  sufficiently  accurate  account  of  all  private  patients,  and  therefore 
none  such  are  included  in  these  returns.  From  the  1st  of  March, 
1844,  to  the  1st  October,  1852,  as  shown  by  the  accompanying  Table  at 
page  108,  the  number  of  ear  patients  whose  diseases  were  registered 
amounted  to  2385 ; — besides  very  many  others  of  whose  disease  no 
note  was  taken  at  the  time. 

When  I  first  commenced  the  study  of  am"al  diseases,  I  believed 
that  in  most  cases  where  I  had  no  positive  evidence  of  disease  in  the 
meatus  or  membrana  tympani,  the  deafness  and  tinnitus  were  caused 
by  some  defect  in  the  nerve  of  hearing,  or  what  is  termed  "  nervous 
deafness."  As,  however,  my  field  of  observation  extended,  and  as 
my  knowledge  of  the  healthy  and  morbid  appearances  of  the  mem- 
brane improved,  I  gradually  began  to  find  that  the  instances  of  deaf- 
ness with  perfectly  healthy  tympanal  membranes  which  fell  under  my 
observation  were  comparatively  few :  while  I  daily  became  familiar- 
ized with  a  variety  of  pathological  appearances  in  these  structures, 
which  I  was  soon  convinced  were  the  result  of  different  forms  of  in- 
flammation of  an  acute  or  chronic  natm-e,  arising  from  some  idio- 
pathic or  specific  cause.  These  appearances  naturally  led  me  to  pay 
particular  attention  to  those  diseases  in  their  early  stages, — the  only 
period  at  which,  in  most  of  them,  art  can  be  of  any  avail. 

As  the  acquisition  of  knowledge  is  progressive,  so  my  means  of 
forming  an  accm-ate  diagnosis  improved  with  my  experience,  and 
therefore  the  value  to  be  attached  to  the  early  years  included  in  this 
Table  is  not  so  great  as  that  for  a  later  period.  I  have  consequently 
divided  the  results  into  two  portions :  the  first  including  three,  the 
second  four  and  a  half,  years.  In  the  first  portion  of  the  Table,  out 
of  706  recorded  cases,  85  were  set  down  to  "nervous  deafness," 
which  I  am  inclined  to  think  was  an  exaggeration,  as  by  a  more  care- 
fully conducted  examination,  and  with  increased  experience,  I  found 
but  18  cases  out  of  1679  in  the  second  period ;  having  observed  since 
the  former  period  that  many  of  the  cases  attributed,  for  want  of  a 
better  name,  to  "nervous  deafness,"  showed  such  manifest  appear- 
ances of  diseased  action  in  the  membrana  tympani,  that  little  doubt 
now  remains  upon  my  mind  that  the  defect  of  hearing  was  to  be  at- 
tributed not  to  paralysis  or  want  of  power  in  the  auditory  nerves, 
but  to  lesions  produced  by  inflammation.  Again,  in  the  first  period 
there  is  no  entry  for  thickening  and  opacity  of  the  membrana  tym- 


106  STATISTICS    OF    EAR    DISEASES. 

pani,  the  unmistakeable  result  of  inflammation,  but  as  many  as  219 
in  the  second ;  and  under  the  head  of  inflammation  of  a  chronic 
character,  we  find  but  82  cases  noted  in  the  first,  and  314  in  the 
second  period. 

Out  of  the  2385  cases  recorded  we  perceive  that  579  were  simply 
cases  of  impaired  hearing  produced  by  impaction  of  the  external  au- 
ditory passage  with  cerumen ;  114  of  so-called  nervous  deafness ;  25 
of  tinnitus  aurium,  unaccompanied  at  the  time  by  deafness  or  any 
apparent  disease ;  14  of  otalgia ;  7  of  deaf-dumbness,  either  conge- 
nital or  acquired ;  2  of  accidental  hemorrhage  from  the  tympanal 
cavity ;  7  of  congenital  malformation ;  20  of  collapsed  membrana 
tympani ;  and  2  of  tumors  of  the  auricle  : — making  in  all  but  770 
cases  of  diseases  of  the  ear  not  directly  traceable  to  inflammation  or 
its  efiects. 

Let  us  reason  by  analogy  on  this  great  preponderance  of  inflamma- 
tory afiections  among  diseases  of  the  ear  from  what  may  be  observed 
of  the  organs  of  sight.  Out  of  11,233  eye  cases  registered  at  St. 
Mark's  Hospital,  but  857  were  diseases  of  the  retina  and  optic  nerve, 
and  only  341  of  these  were  instances  of  uncomplicated  amaurosis,  or 
about  1  to  every  33  of  the  entire.^  Whereas  in  the  registry  of  ear 
diseases  hereunto  appended,  the  proportion  of  nervous  deafness,  in- 
cluding the  exaggerated  entry  in  the  first  period  already  alluded  to, 
is  about  1  in  21 ;  but  by  a  more  accurate  registry  it  is  probable  that 
it  would  bear  a  somewhat  less  proportion  to  the  whole  than  amaurosis 
does  to  the  general  mass  of  diseases  of  the  eye.  In  former  times 
cases  of  loss  of  vision  by  what  is  called  gutta  serena,  and  also  glau- 
coma, were  said  to  be  very  frequent.  Some  time  later,  owing  to  the  im- 
proved condition  of  ophthalmic  pathology  and  diagnosis,  observers 
reduced  both  these  afiections  to  a  smaller  compass  under  the  name  of 
amaurosis.  Still  more  recently,  and  as  practitioners  became  better 
acquainted  with  the  various  forms  of  congestion  and  other  diseases 
of  the  choroid,  and  the  difierent  silent  inflammations  which  may  be 
set  up  in  the  eye,  the  latter  disease  was  still  further  reduced  ;  and  now 
I  think  it  will  be  acknowledged  by  those  who  have  enjoyed  extensive 
opportunities  for  studying  ophthalmic  afi'ections,  that  true  uncompli- 
cated amaurosis,  not  resulting  from  disease  of  the  brain  or  its  mem- 
branes, tumors  within  the  cranium  or  the  orbit,  but  proceeding  from 
simple  paralysis  of  the  optic  nerve  or  retina,  are  comparatively  rare. 

'  See  Report  on  the  Number  and  Condition  of  the  Blind,  in  Ireland  in  March,  1851,  in 
the  Report  of  the  Census  Commissioners  for  that  period,  Part  ii.  page  45. 


STATISTICS    OF    EAR    DISEASES.  107 

When  such  cases  are  pronounced  incurable  at  a  public  institution  or 
in  private  practice,  and  either  told  so  honestly,  or  sent  to  the  country 
to  be  got  rid  of,  or  to  improve  their  health,  broken  down  by  disease 
or  treatment,  they  are  generally  lost  sight  of ;  but  if  we  examine  the 
inmates  of  a  blind  asylum  we  are  at  once  struck  with  the  fact  that 
nine-tenths  of  the  cases  of  loss  of  vision  there  presented  are  the  re- 
sult of  inflammatory  action ;  the  cases  of  pure  unmixed  amaurosis  are 
comparatively  rare,  either  on  account  of  their  actual  scarcity,  or  be- 
cause the  patients  so  affected  have  already  been  carried  off  by  the 
cerebral  disease,  which  was  the  original  cause  of  their  blindness. 

From  an  analysis  of  the  following  Table  we  perceive  that  diseases 
of  the  auricle  and  external  meatus  amount  to  nearly  one-half  of  the 
entire ;  affections  of  the  membrana  tympani,  exclusive  of  collapse, 
number  819,  or  nearly  one-third  of  the  entire  ;  and  diseases  of  the 
middle  ear  amount  to  101,  or  about  a  twenty-third  of  the  whole. 
The  term  otitis  is  here  applied  solely  to  inflammations  of  the  cavity 
of  the  tympanum  ;  but  as  it  is  not  possible  to  limit  inflammatory  ac- 
tion to  the  peculiar  structure  in  which  it  is  originally  set  up,  we  may 
suppose  that  a  large  proportion  of  the  diseases  registered  as  affections 
of  the  external  drum-head  must  have  extended  sooner  or  later  to  the 
internal  surface  of  that  membrane,  and  the  investitures  of  the  cavity 
of  which  it  forms  the  outer  boundary. 

The  subject  of  otorrhoea  is  difficult  to  manage,  either  in  a  statistical 
or  a  nosological  point  of  view,  owing  to  the  variety  of  causes  which 
may  give  rise  to  that  affection,  the  different  portions  of  the  ear  from 
which  it  may  proceed,  its  various  complications,  and  the  several  struc- 
tures which  may  be  originally  or  subsequently  engaged.  The  prin- 
cipal division  made  of  that  disease  in  the  Statistical  Table  is  into  ex- 
ternal, when  the  membrana  tympani  remains  intact :  and  internal, 
from  the  circumstance  of  its  perforation  or  total  destruction,  thereby 
allowing  the  mucous  membrane  of  the  middle  ear  to  be  exposed  to  the 
action  of  the  atmosphere.  The  eleven  cases  of  deaf-dumbness  must 
not  be  taken  as  indicative  of  the  real  proportion  which  that  affection 
bears  to  the  other  diseases  of  the  ear ;  in  this  country  the  number 
of  cases  of  congenital  deafness  applying  to  the  public  institution  are 
always  accidental.  The  statistics  of  that  class  are  set  forth  in  Chap- 
ter VII. 


108 


STATISTICS    OF    EAR    DISEASES. 


Table  showing  the  different  Diseases  of  the  Ear,  registered  at 


Congenital  Malformation  of  Ex- 
ternal Ear, 

Abscess  of  Mastoid  Gland,       .     . 

Disease  of  Mastoid  Process,     .     . 

Eczema  and  Herpes  of  Auricle,  . 

Tumors  in  ditto, 

Inflammation  of  External  Meatus, 

Ditto,  with  Acute  Otorrhcea,     .     . 

Ditto,     "      Chronic      «  .     . 

Otorrhcea,  with  Polypoid  Growths, 

Abscess  in  External  Meatus,    .     . 

Contraction    and    Ulceration    in  ) 
ditto,     .     .     , 5 

Foreign  Bodies  in  ditto,  .... 

Cerumenous  Collections  in  ditto,  . 

Inflammation      of      Membrana  1 
Tympani,  Acute,     ....     J 

Ditto,  Subacute  (Strumous),      .     . 

Ditto,  Syphilitic, 

Ditto,  Chronic, 

Abscess  in  Membrana  Tympani, 

Ulceration    and    Perforation    of } 
ditto,  with  Otorrhcea,  ...     5 

Thickening  and  Opacity  of  Mem-  ) 
brana  Tympani,      .     .     .     .     ^ 

Granular  and  Vascular  ditto,    . 

Collapse    of   Membrana    Tym- ") 
pani, J 

Inflammation  of  Cavitas  Tym-  } 
pani  (Otitis), 5 

Ditto,  with  Caries, 

Hemorrhage  from  Tympanum,    . 

Tinnitus  Aurium, 

Otalgia, 

Nervous  Deafness, 

Post-Febrile  Deafness,     .... 

Deaf-Dumbness, 

Deafness  from  Disease  of  Throat, 

Total,  .     .     . 


■g 

A 

GES  AND 

<0 

Under  5. 

6  to  10. 

11  to  15. 

16  to  20. 

21  to  30. 

(U 

o 

M. 

F. 

M  . 

F. 

M. 

F. 

M. 

F. 

M. 

1 

7 

1 

1 

1 

1 

1 

2 

1 

1 

4 

1 

1 

1 

68 

7 

7 

6 

4 

1 

7 

1 

8 

2 

1 

1 

25 

1 

3 

1 

2 

3. 

5 

12 

1 

2 

2 

1 

4 

1 

516 

39 

30 

62 

45 

49 

50 

41 

54 

33 

33 

64 

4 

2 

2 

13 

8 

7 

4 

9 

3 

14 

1 

1 

2 

2 

2 

6 

1 

1 

2 

1 

1 

579 

11 

4 

27 

23 

24 

11 

13 

15 

52 

40 

113 

4 

11 

6 

8 

8 

9 

10 

15 

16 

24 

1 

1 

2 

2 

3 

2 

2 

2 

3 

2 

396 

6 

5 

19 

17 

19 

7 

32 

32 

43 

46 

2 

55 

2 

2 

3 

9 

6 

9 

9 

219 

1 

3 

9 

7 

14 

22 

33 

29 

7 

•  • 

1 

2 

20 

1 

1 

1 

1 

1 

3 

69 

3 

1 

2 

5 

2 

2 

6 

10 

5 

5 

2 

1 

2 

2 

1 

1 

25 

2 

3 

4 

8 

14 

,   , 

1 

1 

3 

4 

114 

2 

1 

1 

5 

4 

2 

4 

14 

15 

3 

1 

7 

1 

2 

2 

1 

6 

1 

1 

1 

243 

2385 

77 

59 

162 

113 

148 

113 

147 

173 

234 

STATISTICS    OP    EAR    DISEASES. 


109 


St.  Mark's  Hospital,  from  1st  March,  1844,  to  1st  October,  1852. 


Sexes. 


31  to  40. 


12 


17 


60  and 
Upwards. 


10 


20 


11 


234  1154     186    104    156      82      1353      1032    706      1679 


Total. 


2 

2 
19 

1 
12 

7 

274 

40 


2 
365 

56 

16 

3 

234 

2 

29 

127 
4 
7 

41 

2 
1 
9 
9 
64 
3 
5 
4 


2 

49 

1 

•  13 

5 

242 

24 

6 


214 

57 

8 

162 

26 

92 

3 

13 

28 

3 
1 

16 
5 

50 


Pekiods. 


1844 


1847, 


2 
17 

13 
3 

185 
26 


160 
39 


6 

2 

2 
51 

2 
12 

9 

331 

38 

14 


2 
419 

74 

24 

3 

314 


52 

219 

2 

10 

22 

5 

1 

11 

10 

29 

3 

7 


Diseases, 


5  Congenital  Malformation  of  Ex- 
(      ternal  Ear. 

Abscess  of  Mastoid  Gland. 

Disease  of  Mastoid  Process. 

Eczema  and  Herpes  of  Auricle 

Tumors  in  ditto. 

Inflammation  of  External  Meatus. 

Ditto,  with  Acute  Otorrhcea. 

Ditto,     "      Chronic       " 

OtorrhcEa,  with  Polypoid  Growths. 

Abscess  in  External  Meatus. 
^  Contraction    and    Ulceration    ii 
(      ditto. 

Foreign  Bodies  in  ditto. 

Cerumenous  Collections  in  ditto. 
5  Inflammation  of  MembranaTym- 
(      pani,  Acute. 

Ditto,  Subacute  (Strumous). 

Ditto,  Syphilitic. 

Ditto,  Chronic. 

Abscess  in  Membrana  Tympani. 
C  Ulceration    and    Perforation    of 
l      ditto,  with  Otorrhcea. 
C  Thickening  and  Opacity  of  Mem- 
(      brana  Tympani. 

Granular  and  Vascular  ditto. 
C  Collapse    of    Membrana    Tym- 
(      pani. 

(  Inflammation    of   Cavitas    Tym- 
(      pani  (Otitis). 

Ditto,  with  Caries. 

Hemorrhage  from  Tympanum. 

Tinnitus  Aurium. 

Otalgia. 

Nervous  Deafness. 

Post-Febrile  Deafness. 

Deaf-Dumbness. 

Deafness  from  Disease  of  Throat. 

Total. 


110  Kramer's  statistics. 

Of  the  entire  cases  recorded,  the  sexes  are  in  the  proportion  of  100 
males  to  79  females  ;  these  proportions,  however,  vary  according  to  the 
different  diseases :  thus  in  eczematous  and  kindred  affections  of  the  au- 
ricle and  meatus  the  females  predominated,  whereas  among  the  cases 
of  deafness  arising  from  collections  of  cerumen,  the  male  sex  formed 
the  majority.  In  cases  attributed  to  nervous  deafness  the  females 
predominated  ;  whereas  both  in  otorrhoea  and  all  the  inflammatory 
affections,  the  sexes  were  nearly  equal ;  but  cases  of  otorrhoea  at- 
tended with  polypus  were  much  more  frequent  in  the  male  than  in  the 
female.  With  respect  to  the  relative  frequency  of  aural  diseases  at 
particular  periods  of  life,  the  preceding  Table  affords  accurate  infor- 
mation, as  the  ages  of  the  different  patients  were  carefully  registered, 
— not  the  ages  at  which  the  disease  appeared,  but  that  at  which  the 
patients  applied  to  the  Institution.  This  Table,  it  must  be  remem- 
bered, does  not  include  all  the  diseases  enumerated  in  the  Nosology, 
or  specified  in  this  work,  as,  for  the  purposes  intended  at  a  public  in- 
stitution, too  minute  a  subdivision  would  be  disadvantageous,  even 
were  it  possible,  to  continue  it  for  a  number  of  years.  It  is  unneces- 
sary here  to  enter  further  into  its  minutige,  to  discuss  its  results,  or 
enlarge  upon  the  deductions  which  might  be  drawn  from  it ;  like  all 
such  Tables  it  must  be  more  or  less  defective ;  but  so  long  as  statisti- 
cal calculations  are  admitted  in  medicine,  it  is,  like  others  of  the  same 
class,  entitled  to  its  value. 

In  1845  Dr.  Kramer  published  his  Beitrdge  zur  OlirenJieilhunde, 
in  which  he  has  given  an  extensive  statistical  chart  and  nineteen 
tables  connected  with  diseases  of  the  ear.  The  number  of  cases 
therein  recorded  amounted  to  2000,  of  which  but  5  were  diseases  of 
the  auricle,  and  281,  or  one-seventh  of  the  whole,  were  diseases  of 
the  external  auditory  passage,  including  under  the  head  of  inflamma- 
tion of  the  skin  213  cases  of  impactions  with  wax ;  a  position  which  yet 
remains  to  be  proved.  He  includes  all  the  diseases  of  the  tympanal 
membrane  with  those  of  the  external  ear,  whereas,  in  my  opinion, 
they  belong  equally,  if  not  more  so,  to  those  of  the  middle  ear ;  in- 
deed, I  believe  that  the  chronic  as  well  as  the  acute  inflammation  of 
the  membrane  is  accompanied  by  disease  in  the  middle  ear  more  fre- 
quently than  disease  in  the  auditory  passage.  Of  the  2000  cases 
observed,  the  inflammations  of  the  tympanal  membrane  amounted  to 
442,  or  something  less  than  one-fourth  of  the  whole ;  and  of  these 
cases,  45  were  acute,  and  397  chronic  inflammations.  164,  or  about 
one-twelfth  of  the  whole,  were  inflammations  of  the  middle  ear,  but 


KRAMER'S    STATISTICS.  Ill 

wMcli  he  does  not  tell  us  -were  originally  connected  with,  or  subse- 
quently produced  changes  in,  the  membrana  tympani.  If  in  these 
164  cases  the  inflammation  of  the  mucous  membrane  of  the  middle 
ear  was  confined  to  that  lining  the  bony  parietes  of  this  cavity, — not 
extending  over  the  extensive  surface  stretched  upon  the  back  of  the 
membrana  tympani,  not  propagating  inflammatory  action  there,  and 
producing  the  eflects  of  inflammation  upon  transparent  or  diaphanous 
membranes, — as  we  see  it  does  upon  the  aqueous  membrane  lining 
the  back  of  the  cornea, — then  have  we  no  analogy  for  such  a  state 
of  things  in  any  of  the  other  departments  of  Pathology.  To  these 
164  cases  of  inflammation  of  the  lining  of  the  tympanum,  he  has  added 
30  of  alterations  in  the  Eustachian  tube, — 28  of  stricture,  and  2  of 
occlusion, — but  for  which  he  had  no  other  warrant  than  that  he  was 
unable  to  pass  air  or  solid  instruments  through  the  tube.  There  were 
4  cases  of  inflammation  of  the  periosteum  of  the  cavity — in  all,  198 
diseases  of  the  middle  ear,  or  one-tenth  of  the  whole.  Among  the 
diseases  of  the  ear  he  has  included  46  instances  of  deaf-dumbness. 
With  most  of  these  statistics  we  find  no  fault ;  and  to  the  various 
tables  exhibiting  the  causes,  ages,  sexes,  &c.,  we  must,  in  common 
with  all  who  will  examine  them,  award  to  the  zeal  and  industry  of 
their  author  the  amount  of  credit  which  they  deserve.  Some  of  these 
tables,  are,  however,  more  curious  than  valuable ;  thus  No.  VIII.  shows 
the  fatherland  or  country  of  his  difierent  patients  from  all  parts  of 
Europe  and  from  America. 

When  we  come  to  examine  into  the  chief  cause  of  deafness  enume- 
rated by  the  Berlin  aurist,  we  at  once  perceive  that  his  favorite  theory 
of  "nervous  deafness"  has  been  pressed  into  the  service,  and  this 
item  made  to  exhibit  a  magnitude  which  we  have  strong  hopes  of  see- 
ing Dr.  Kramer  himself  one  day  criticise  with  more  severity  than  we 
are  now  willing  to  do  for  him.  Of  the  entire  number  of  cases  re- 
corded, 1028,  or  somewhat  more  than  one-half  the  whole,  are  set 
down  as  "  Nervose  Tauhheit.''  The  most  that  can  be  said  of  these 
1028  cases,  many  of  which  may,  I  doubt  not,  have  been  caused  by 
affections  of  the  auditory  nerve,  is,  that  in  these,  the  parts  capable 
of  inspection  exhibited  to  his  eye  no  symptoms  of  disease.  In  which 
case,  he  says,  "the  use  of  the  ear  catheter  is  the  only  means,  either 
by  blowing  through  it,  or  by  injecting  compressed  air  from  the  air- 
press,  or  by  the  introduction  of  a  catgut  string,  or  a  small  whalebone, 
or  ivory  probe,  to  learn  the  condition  of  the  Eustachian  tube  and  the 
cavity  of  the  tympanum,  and  thereby,  in  the  case  in  question,  to 


112  Kramer's  nervous  deafness. 

judge  of  the  condition  of  the  auditory  nerve  /"  But  even  this 
hazardous  mode  of  making  an  examination, — by  introducing  a  foreign 
substance  into  the  cavity  of  the  tympanum  ! — is  at  best  but  a  nega- 
tive proof.  By  it  the  condition  of  the  ossicula,  the  membrane  of  the 
fenestra  rotunda,  the  fine  mucous  membrane,  with  its  nerves,  lining 
the  tympanic  cavity,  the  state  of  the  labyrinth  and  the  internal  ear, 
or  the  brain,  cannot  he  investigated}  Is  there  any  other  organ  of 
sense  in  which  the  affection  of  the  nerve  bears  the  same  proportion 
to  all  the  other  diseases  of  the  part  as  this  ?  Would  any  table  of  the 
affections  of  the  eye  be  acknoAvledged  as  authentic  in  which  more 
than  one-half  of  the  diseases  of  that  organ  were  ascribed  to  amau- 
rosis, or  amaurosis  not  consequent  upon  some  inflammatory  condition  ? 
Let  us  ask  what  Dr.  Kramer  means  by  nervous  deafness  ?  He  him- 
self answers,  in  the  first  edition  of  his  Erhenntniss  und  Heilung  der 
OhrenTcranhheiten,  that  such  cases  are  those  in  which  "  we  find  the 
hearing  altered  and  debilitated  without  any  organic  abnormal  state  in 
any  part  of  the  whole  organ  of  hearing"  (see  Bennett's  translation,  page 
255).  And  in  the  paragraph  following  he  adds,  with  great  justice, 
"  This  nervous  deafness  has  hitherto  been  frequently  misused  as  a 
cloak  for  ignorance  and  want  of  skill  in  any  doubtful  or  obscure 
disease  of  the  ear."  Now,  all  the  value  we  derive  from  the  foregoing 
definition  is,  as  already  stated,  that  the  examination  of  such  cases 
afforded  negative  evidence  as  to  the  existence  of  disease  at  the  moment 
in  those  parts  visible  to  the  eye,  or  the  condition  of  which  was  appre- 
ciable by  the  ear  by  means  of  the  air  douche,  &c.  Sixteen  years 
ago  the  author  divided  this  nervous  deafness  into  that  attended  with 
tinnitus,  or  the  erethitic,  which  he  believed  to  be  amenable  to  treat- 
ment, and  the  torpid,  in  which  there  was  a  total  absence  of  tinnitus 
throughout  the  whole  course  of  the  disease.  Let  us  read  from  Dr. 
Bennett's  faithful  translation  of  the  work  just  alluded  to  what  was  Dr. 
Kramer's  exposition  of  the  physical  signs  of  nervous  deafness  in  the 
year  1836.  All  traces  of  cerumenous  secretion  vanish  by  degrees ; 
the  Eustachian  tube,  as  also  the  middle  ear,  is  in  general  free  and 
open,  and  a  stream  of  air  passes  readily  up  to  the  tympanal  mem- 
brane ;  and  then  he  says,  "In  both  forms  of  nervous  deafness"  (i.  e. 
the  torpid  and  erethitic)  "I  have  almost  always  found  the  memhrana 
tympani  white  like  paper,  and  opaque ;  probably  in  consequence  of 

•  A  very  admirable  analysis  of  Kramer's  Statistics  appeared  in  the  British  and  Fo- 
reign Medical  Review  for  July,  1847. 


Kramer's  nervous  deafness.  113 

the  action  of  its  absorbent  vessels  having  been  impaired."  Now,  had 
Dr.  Kramer  been  conversant  with  the  normal,  healthy  condition  of 
the  membrana  tympani,  he  would  have  known  that  it  was  shining, 
diaphranous,  or  semi-transparent,  and  of  a  yellow-gray  tint  (except 
towards  its  superior  attachment,  and  along  the  line  of  insertion  of  the 
handle  of  the  hammer  bone),  somewhat  the  color  of  gold-beater's  skin, 
or,  what  bears  a  still  closer  similitude  on  account  of  its  greater  thick- 
ness and  fleshy  tint,  the  thin  sheet  gutta  percha  which  has  been  lately 
introduced  for  surgical  purposes. 

To  state,  then,  that  a  texture,  the  normal  condition  of  which  is 
known  to  every  observer  of  it  in  the  living  healthy  state,^  to  be  what 
I  have  described,  is  "white  like  paper,  and  opaque,"  exhibits  either 
defective  powers  of  observation,  insufficient  means  for  investigation, 
or  a  want  of  knowledge  of  the  natm'al  condition  of  the  parts.  What 
would  be  thought  of  an  ophthalmic  surgeon  who,  in  describing  a  case 
of  amaurosis,  stated  that  all  the  structures  were  normal,  but  that,  at 
the  same  time,  the  cornea  was  opaque,  or  even  cloudy  ?  Yes,  I  do 
believe  that  in  the  cases  observed  by  Kramer,  and  described  in  his 
original  work,  the  membrana  tympani  was  opaque,  like  white  paper, 
because  it  had  been  previously  subjected  to  inflammatory  action,  and 
the  opaque  deposit  was  the  well-known  consequence  thereof.  As  to 
his  mode  of  accounting  for  the  opacity  by  a  want  of  action  in  the 
absorbent  vessels,  I  do  not  think  it  requires  refutation.  Some  of  the 
worst  cases  of  defective  hearing,  apparently  induced  by  paralysis  or 
impaired  function  of  the  auditory  nerves,  and  which  are  of  many 
years'  standing,  have  perfectly  normal  tympanal  membranes.  Further- 
more, if  those  cases  attributed  to  nervous  deafness  showed  such  mani- 
fest disease  in  the  external  membrane  of  the  tympanum,  which  was 
seen,  how  much  greater  may  not  have  been  the  morbid  changes  in  the 
parts  beyond  it,  both  in  the  middle-  and  internal  ear,  which  were  not 
seen? 

In  the  Statistics  already  alluded  to,  Dr.  Kramer  modified  his 
former  views  as  regards  the  division  of  nervous  deafness,  and  classi- 
fied both  under  the  general  head  of  diseases  of  the  inner  ear — as 

1  Anatomists  seldom  see  the  membrana  tympani  except  in  the  dead  state,  when  par- 
tial decomposition  has  set  in,  and  its  external  cuticular  layer  has  become  thickened  and 
opaque  :  therefore  it  is  that  their  descriptions  of  this  structure  are  not  as  accurate  as  of 
other  parts  of  the  human  body.  Suppose  anatomists  were  to  describe  the  cornea  only 
from  the  condition  it  presents  in  subjects  five  or  six  days  dead,  how  little  would 
have  been  written  about  the  polish,  transparency,  and  curvature  of  that  beautiful 
structure ! 


114  Kramer's  statistics. 

nervose  Taubheit.  Again,  in  1849,  in  the  second  edition  of  Ms  prin- 
cipal work  on  Diseases  of  the  Ear,  he  defines  the  affections  in  the 
chapter  devoted  to  the  consideration  of  nervous  diseases  of  the  inner 
ear  as,  hard-hearingness,  and  deafness  ;  and  without  any  preliminary 
observations,  at  once  enters  into  the  details  of  cases  and  observations 
in  proof  of  the  so-called  nervous  deafness.  And  in  almost  all  the 
cases  recorded  in  that  section  (p.  668,  from  No.  128  to  No.  165)  we 
read  of  the  membrana  tympani  being  clear,  shining,  and  transparent, 
thus  differing  from  his  observations  made  in  1836,  when  the  same 
structure  was  almost  always  white  like  paper,  and  opaque. 

Mr.  Toynbee's  observations  and  dissections,  having  a  direct  influ- 
ence on  the  statement  set  forth  in  these  statistics,  naturally  attracted 
much  attention,  and  would,  unless  disproved  by  counter  facts,  be  a 
"heavy  blow  and  a  great  discouragement"  to  Dr.  Kramer's  views, 
and,  consequently,  in  the  Medical  Times  and  Grazette  (for  October 
16th,  1852),  the  Prussian  surgeon  is  again  in  print  on  the  subject, — 
fearful  that  his  English  professional  brethren  should  not  fully  appre- 
ciate the  results  of  his  "  extensive  aural  practice  of  upwards  of 
twenty-two  years."  He  begs  his  readers  to  be  satisfied  with  his 
pathological  (?)  sketch  of  real,  not  fancied  diseases,  in  contradistinc- 
tion to  the  researches  of  Mr.  Toynbee.  Appended  to  that  paper 
is  a  table,  republished  from  page  113  of  his  OhrenheilTcundie  in  den 
Jahren  1849  und  1850,  giving  the  result  of  4000  cases, — 2000  addi- 
tional to  the  statistics  published  in  1845, — and  there  again  nervous 
diseases  of  the  ear  are  made  to  exhibit  the  same  proportion  to  the 
entire  which  they  did  in  the  previous  calculations,  for  we  find  1875 
cases  of  nervous  deafness  out  of  the  additional  2000  set  down  under 
the  respective  heads  of  "hardness  of  hearing,"  and  "deafness." 
Time  and  pathological  research  will  eventually  determine  the  matter 
in  dispute,  but  at  present  it  will  be  for  the  practical  surgeon  to  judge 
between  Mr.  Toynbee's  dissections,  which  he  still  possesses,  and  which 
can  be  examined  by  any  person  who  pleases  to  wait  upon  him, — but 
the  inferences  from  which  Kramer  says  "  are  of  a  purely  theoretical 
character,"  inducing  "false  consequences  and  conclusions," — and 
the  figures  given  as  the  result  of  the  latter's  private  practice,  and 
set  forth  so  ostentatiously  in  his  various  publications. 

Let  the  profession  also  compare  the  result  of  the  observations  and 
brief  details  of  facts  set  forth  in  the  tabulated  abstract  of  200  cases 
faithfully  taken  as  they  presented  at  a  public  hospital,  in  the  presence 
of,  and  equally  observed  by,  a  number  of  medical  men  and  intelligent 


tschakner's   statistics.  115 

students,  many  of  wliom  will  no  doubt  recognise  these  cases  wlien 
thej  read  them,  given  at  the  conclusion  of  this  chapter,  with  the 
figures  afforded  from  time  to  time  by  Dr.  Kramer.  Far  be  it  from 
me  to  deny  the  great  prevalence  of  what  is  termed  nervous  deafness ; 
in  the  foregoing  observations  I  merely  doubt  the  proportion  which, 
according  to  the  German  aurist's  belief,  they  bear  to  the  entire  mass 
of  diseases  of  the  organ  of  hearing.  It  is  easy  to  give  names  to  dis- 
eases and  to  attach  numbers  thereto,  it  is  another  matter  faithfully 
to  record  the  appearances  which  each  case  presented  during  life  or 
exhibited  after  death.  When  Dr.  Kramer  has  demonstrated  to  a 
public  class  of  students  and  practitioners  capable  of  observing  for 
themselves — the  only  true  method  of  clinical  investigation — the  healthy 
character  of  the  membrana  tympani  in  one-half  of  the  next  2000 
cases  which  he  publishes,  I  think  his  figures  may,  but  not  until  then, 
be  placed  in  comparison  with  the  facts  described  by  British  observers. 
Statistical  tables  and  calculations  are  really  valuable  only  when  we 
can  rely  upon  the  original  investigations  from  which  they  were  de- 
duced ;  if  the  materials  have  been  loosely  collected,  or  for  any  special 
purpose,  or  to  support  any  preconceived  theory,  such  circumstances 
naturally  influence  the  value  to  be  set  upon  all  subsequent  arrange- 
ments, no  matter  how  ingenious.  Statistical  calculations  remind  one 
of  the  kaleidoscope,  which,  when  turned  or  shaken,  presents  new  and 
beautiful  combinations  of  figure  and  color,  irrespective  of  the  objects 
which  produced  such  being  crooked  pins  and  glass  beads  or  spangles 
and  diamonds. 

Dr.  Tscharner  of  Berne  published  in  1849  the  result  of  200  cases 
in  a  small  tract,  Beitrag  zur  Statistih  der  OhrenhraiihJieiten,  the 
sexes  being  in  the  proportion  of  115  men  to  85  women.  Among 
these,  both  ears  were  affected  in  158  cases ;  the  right  in  22,  and  the 
left  in  20.  The  diseases  recorded  affected  the  different  portions  of 
the  organ  of  hearing  in  the  following  proportions  : — The  auricle,  10  ; 
external  meatus  and  auditory  canal,  163  ;  the  membrana  tympani, 
122 ;  the  cavitas  tympani,  70  ;  the  Eustachian  tube,  74 ;  and  the 
labyrinth,  72 :  but  the  diseases  affecting  several  of  these  parts  co- 
existed. The  proportion  of  diseases  of  the  labyrinth  which  the  author 
has  recorded,  and  which  we  are  led  to  suppose  he  diagnosed,  would, 
if  true,  be  curious.  It  is  unnecessary  to  follow  the  author  through 
his  various  and  ingenious  tables  further.  Mr.  Yearsley  and  Dr. 
Schmalz  have  likewise  written  upon,  and  published  tables  of  the  sta- 
tistics of  ear  diseases. 


116  toynbee's  dissections. 

As  already  stated  at  page  49,  Mr.  Toynbee  has  dissected  the  ears 
of  750  persons  furnished  to  him  from  different  sources ;  and  of  these 
he  has  published  the  result  of  the  examination  of  915  ears.-^  Of 
these,  303  were  in  a  healthy  state ;  and  on  this  small  proportion  of 
only  one-third  found  in  a  normal  condition,  the  author  remarks,  "  To 
those,  however,  who  have  given  the  subject  much  consideration,  and 
who  are  aware  of  the  wide-spread  prevalence  of  deafness  in  its  vary- 
ing degrees  among  all  classes  of  society,  the  dissections  will  not, 
perhaps,  be  thought  to  exhibit  any  unusual  proportion  of  diseased 
to  healthy  specimens."  Of  the  remaining  612  ears,  184  had  be- 
longed to  persons  who  were  known  during  life  to  have  been  deaf, 
and  these  are  the  really  valuable  cases,  though  it  would  have  much 
increased  their  value  had  the  amount  of  deafness  and  other  symp- 
toms during  life  been  recorded ;  70  showed  upon  dissection  such 
manifest  traces  of  disease  as  left  little  doubt  that  the  persons  must 
have  had  in  life  defective  hearing ;  and  358  were  believed  by  the 
author  to  be  in  a  state  of  incipient  deafness.  The  following  summary 
gives  the,  result  of  these  investigations ;  but  so  many  ears  exhibited 
morbid  appearances  in  different  parts,  that  the  totals  of  the  different 
sections  are  not  to  be  considered  as  making  up  the  entire  612  ears. 

The  external  meatus  showed  disease  in  80  instances,  or  1  in  lOJ : 
consisting  of, — collections  of  cerumen  and  epithelium,  58  ;  of  pus  and 
epithelium,  13  ;  contraction  of  canal  with  alterations  in  its  lining  mem- 
brane and  osseous  parietes,  9. 

The  membrana  tympani  was  diseased  in  209  instances,  or  nearly 
1  in  every  3  ;  of  these  there  were,  with  the  membrane  white,  thick- 
ened, or  vascular,  52 ;  concave  externally  or  flat,  15 ;  concave,  and 
adhering  to  promontory,  21 ;  concave,  with  deposits  of  calcareous 
matter,  4 ;  perforated,  or  altogether  destroyed,  51 ;  and  adherent  to, 
or  connected  by  bands  with,  the  ossicula  or  promontory,  66. 

The  cavitas  tympani  presented  evidences  of  disease  in  the  follow- 
ing proportions  :  it  contained  morbid  collections  in  107  examinations, 
or  about  1  in  every  6,  to  speak  in  round  numbers;  consisting  of, — 
collections  of  mucus,  with  the  lining  membrane  healthy,  43  ;  and  with 
the  membrane  thickened,  5  ;  filled  with  portions  of  cerumen  and  epithe- 
lial scales,  the  result  of  destruction  or  perforation  of  the  membrana 
tympani,  2  ;  containing  pus,  with  the  membrane  thickened,  15  ;  filled 

'  See  the  Medico-Chirurgical  Transactions,  vols.  xxiv.  1841,  xxvi.  1843,  xxxii.  1849, 
— this  last  contains  tables  for  the  entire. 


toynbee's  dissections.  117 

■with  blood  4  ;  mth  serum  or  lymph,  10  ;  scrofulous  matter,  20  ;  oily 
matter,  1 ;  and  calcareous  matter,  7. 

The  mucous  membrane  of  the  cavitas  tympani  was  diseased  in  310 
cases,  or  more  than  one-half  of  those  examined.  In  66  instances  it 
was  more  vascular  than  natural ;  in  179  it  was  thickened  ;  in  22  so 
thick  as  to  bury  the  whole  of  the  stapes ;  in  8  so  thick  as  to  fill  the 
tympanum;  and  in  5  it  was  pulpy.  The  remaining  examinations 
showed  the  membrane  ulcerated  and  thick,  20 ;  with  black  pigment 
secreted  beneath  it,  2  ;  with  blood  effused  under  it,  8  ;  and  with  serum 
in  the  same  position,  1.  It  is  probable,  however,  that  some  of  these 
latter  appearances  may  have  been  post  mortem  products,  and  that 
many  of  the  characters  detailed  in  this  section  generally  may  have 
resulted  from  the  diseases  which  were  the  immediate  causes  of  death 
in  the  patients,  and  not  from  any  previous  affections  in  the  organs  of 
hearing. 

Bands  of  adhesion  were  found  to  exist  in  the  cavity  of  the  tympa- 
num in  179  cases,  or  1  in  3*42  of  the  whole.  These  bands  passed  be- 
tween the  stapes  and  promontory  in  130  instances  ;  were  connected 
with  the  incus,  stapes,  and  promontory  in  8 ;  joined  the  malleus 
with  surrounding  parts  in  12;  connected  all  the  ossicles  in  13;  the 
ossicles  with  the  promontory  in  9 ;  the  tensor  tympani  muscle  and 
the  stapes  in  3 ;  and  the  chorda  tympani  nerve,  with  the  adjacent 
parts,  in  4. 

The  state  of  the  ossicula  is  thus  described :  the  malleus  adherent  to 
the  promontory,  1 ;  removed  by  absorption,  ulceration,  or  caries,  6  ; 
and  found  with  incus  in  mastoid  cells,  1 ;  the  incus  was  in  whole  or 
in  part  removed  in  10  cases  ;  disconnected  from  stapes  and  malleus 
in  3 ;  the  stapes  was  found  either  partially  or  completely  anchylosed, 
or  more  firmly  attached  than  natural  with  the  fenestra  ovalis,  in  30 
instances ;  disconnected  or  in  a  state  of  absorption,  4 ;  and  project- 
ing into  vestibule,  1 ;  all  the  ossicles  were  either  removed,  carious,  or 
disconnected,  in  5  ears.  Thus  the  number  of  cases  in  which  the  ossi- 
cles were  diseased  or  displaced  amounted  to  61,  or  one-tenth  of  the 
whole,  a  proportion  which  will  not  appear  exaggerated  to  persons  con- 
versant with  the  destructive  results  which  follow  otorrhoea  with  expo- 
sure of  the  tympanal  cavity. 

The  osseous  walls  of  the  tympanum  were :  thickened,  1 ;  carious, 
2  ;  partially  deficient  superiorly,  54  ;  and  inferiorly,  22.  The  caro- 
tid canal  was  contracted  3  times,  making  in  all  82  cases  of  disease  of 
the  bony  parietes,  or  1  in  every  7  "46. 


118         toynbbe's  keseaeches. 

The  membrane  of  the  fenestra  rotunda  was  diseased  5  times ;  the 
tensor  tympani  muscle  atrophied,  7 ;  and  attached  to  stapes  once. 

The  Eustachian  tube  showed  symptoms  of  disease  in  21  of  the  ex- 
aminations, or  1  in  29  ;  contained  mucus,  10  ;  its  lining  membrane 
thickened,  vascular,  or  congested,  8 ;  and  with  bands  connecting  its 
parietes,  3.  It  must,  however,  be  remarked  that  it  was  only  the  upper 
portion  of  the  tube  which  was  submitted  to  examination. 

The  internal  ear  exhibited  the  following  peculiarities :  the  mem- 
branous laybrinth  thickened,  4  ;  atrophied,  6  ;  the  labyrinthine  fluids 
deficient,  8  ;  the  vestibule  and  cochlea  containing  bloody  serum,  1 ; 
pus,  1 ;  a  band  crossing  the  vestibule,  1. 

Considerable  difficulty  must  always  be  experienced  in  dissecting, 
or  in  discovering  pathological  changes  in  the  internal  ear,  particularly 
in  measuring  any  deficiency  of  its  natural  fluids.  We  find  all  the 
dissections  of  the  internal  ear  in  the  column  for  the  184  persons  pre- 
viously known  to  be  deaf.  The  following  observations  upon  these 
dissections  are  so  faithful,  and  so  much  in  accordance  with  my  own 
ideas  upon  the  subject,  that  I  insert  them.  "  The  fact  of  a  thickened 
or  otherwise  deranged  state  of  the  mucous  membrane  lining  the  tym- 
panic cavity  being  one  of  the  most  common  pathological  conditions 
of  the  organ  of  hearing,  is  the  broadest  general  result  of  the  dissec- 
tions ;  and  as  cases  carefully  examined,  noted,  and  studied  as  they 
have  arisen  in  practice,  lead  to  the  same  conclusion,  I  have  little  hesi- 
tation in  stating  disease  of  that  membrane  to  be  the  most  usual  cause 
of  deafness.  What  are  the  history  and  symptoms  of  the  great  ma- 
jority of  cases  of  deafness  unattended  by  discharge  ?  Cold  has  been 
caught,  uneasiness  has  been  felt,  renewed  attacks  of  cold  have  added 
to  the  severity  of  the  symptoms  ;  advice  is  at  length  sought,  and  ex- 
amination shows  the  external  meatus  deprived  of  cerumen,  and  fre- 
quently deficient  in  natural  sensibility,  while,  towards  the  membrana 
tympani,  its  appearance  is  red  and  smooth  ;  the  membrana  tympani  is 
entire,  its  surface  shines,  but  it  is  hazy,  opaque,  or  as  white  as  parch- 
ment, and,  consequently,  the  handle  of  the  malleus  may  be  discerned 
with  varying  degrees  of  distinctness,  or  cease  to  be  visible  at  all. 
Upon  a  forcible  expiration  with  closed  nostrils,  the  air,  by  means  of 
the  otoscope,'  can  almost  always  be  heard  to  enter  the  tympanum,  not 

'  Otoscope — an  elastic  stethoscope,  eighteen  inches  long,  the  ends  tipped  with  ivory; 
one  extremity  of  which  is  inserted  into  the  meatus  of  the  patient,  and  the  other  applied 
to  that  of  the  examiner. 


THE    REGISTKT    OF    CASES.  119 

gradually,  ho"wever,  as  when  the  organ  is  healthy,  but  with  a  puffing, 
bubbling,  or  cracking  sound,  as  though  impeded  in  its  progress." 

I  have  at  page  63  described  the  method  of  taking  cases  at  St. 
Mark's  Hospital.  The  history,  progress,  and  treatment  of  the  first 
twenty-four  cases  in  the  following  Registry  have  been  already  detailed 
at  length  in  the  Medical  Times  and  Gazette,  for  1851  and  1852,  a 
reference  to  which  will  show  the  manner  in  which  they  were  reported ; 
and  portions  of  them  are  inserted  in  the  body  of  this  work.  The 
remainder  are  susceptible  of  publication  like  the  former,  did  space 
permit.  From  the  voluminous  notes  of  these,  the  following  abstract 
of  200  instances  which  presented,  in  succession,  during  the  early  part 
of  the  year  1850,  has  been  drawn  up.  Many  other  cases  occurred  of 
simple  impaction  of  the  external  auditory  canal  with  cerumen,  which 
have  not  been  included  in  the  following  abstract,  except  where,  upon 
the  removal  of  the  mechanical  impediment,  the  lining  of  the  canal,  or 
the  external  surface  of  the  membrana  tympani,  appeared  diseased  from 
other  causes,  or  in  consequence  of  the  long-continued  presence  of  the 
oJBFending  body. 

Sex  and  Age. — From  an  examination  of  the  following  Registry, 
we  learn  that  of  the  two  hundred  persons  afiected,  101  were  males, 
and  99  females ;  their  ages  being  in  the  following  proportions : — 
Under  five  years,  4 ;  from  five  to  ten  inclusive,  19 ;  from  ten  to 
twenty,  63  ;  twenty  to  forty,  82  ;  forty  to  sixty,  29  ;  and  above  that 
age,  3. 

Ear  affected. — In  27  instances  both  ears  were  similarly  and  nearly 
equally  afiected,  in  which  case  a  single  entry  opposite  the  letter  B 
was  deemed  sufficient.  In  100  instances  both  ears  were  diseased,  but 
the  duration,  hearing  distance,  morbid  appearances,  and,  in  some 
cases,  the  cause,  varied  considerably  on  each  side.  Generally  speak- 
ing, the  ear  most  seriously  afiected  is  that  first  noted.  In  35,  the 
right,  and  in  38,  the  left  ear  alone  were  affected.  Where  the  record 
of  but  one  ear  is  inserted,  the  other  was  normal.  In  all  cases  the 
entry  was  made  when  the  patient  first  applied  at  the  Institution ;  the 
progress  and  subsequent  appearances,  increased  by  the  advances  of 
disease,  or  modified  by  treatment,  have  not  been  taken  into  account — 
the  object  being  to  record  the  exact  state  in  which  each  case  of  a 
given  number,  taken  without  selection,  presented. 


120 


REGISTRY    OF    EAR    CASES. 


No. 
of 

Sex. 

Age. 

Ear 

affec- 

Duration 
of 

Hearing 

State  of  Auricle. 

State  of  External  Meatus  and  Canal. 

Case. 

Yrs. 

ted. 

Disease. 

Distance. 

r 

R. 

14  years. 

8  inclies. 

Normal. 

Dry,  white,  and  polished ;  had  dis- 

1 

M. 

20^ 

charge  formerly. 

2 

F. 

25 

L. 
R. 

Ditto. 
4  years. 

6  inclies. 
5  inches. 

Ditto. 
Normal. 

Ditto 

Filled  with  muco-purulent  discharge. 

3 

M. 

19 

R. 

Touching. 

NoriTial ;    post- 
aural  gland  in 

Normal, 

a  state  of  sup- 

puration. 

r 

L. 

1  month. 

Touching. 

Normal. 

Dry,  polished,  gray ;  no  cerumen,  . 

4 

M. 

30-<^ 

I 

R. 

Ditto. 

None. 

Ditto. 

Pale ;  more  polished  than  left.    .     . 

5 

M. 

25 

L. 

4  inches. 

Normal. 

Impacted  with  hard,  inspissated  cer- 

umen ;  on  its  removal,  cuticle  thick- 

ened and  white. 

r 

R. 

6  montlis. 

None. 

Normal. 

Long  and  tortuous ;  lining  membrane 

6 

M. 

20  <^ 

natural. 

1 

L. 

Ditto. 

On  pressure 
Touching. 

Ditto. 

Ditto 

> 

U 

1  year. 

Normal. 

Filled  with  creamy  fetid  discharge. 

7 

F. 

W 

through  which  a  reddish  polypus  ap- 
pears, growing  from  fundus  of  canal. 

^ 

R. 

Ditto. 

3  inches. 

Ditto. 

Coated  with  discharge  ;  membrane 
thickened. 

\ 

R. 

4  years. 

6  inches. 

Normal. 

Filled  with   discharge ;   membrane 

8 

F. 

20^ 

pinkish. 

I 

L. 

Ditto. 

On  pressure 

Ditto. 

Dry  and  scaly 

9 

F. 

30  i 

R. 

Years. 

3  inches. 

Normal. 

Normal 

r 

L. 

12  inches. 
None. 

Ditto. 

Normal. 

Ditto 

L. 

2  months. 

Dry;  no  cerumen 

10 

M. 

25<^ 

I 

R. 

Ditto. 

2  inches. 

Swollen. 

Filled  by  an  abscess  of  integument. 

11 

F. 

30 

B. 

Years. 

Normal. 

Remarkably  small 

12 

M. 

.o{ 

R. 

Years. 

3  inches. 

Normal. 

Normal 

13 

M. 

I 

11  \ 

L. 

Touching. 
3  inches. 

Ditto. 
Normal. 

Ditto 

L. 

14  days. 

Filled  with  whitish  discharge.    .     . 

R. 

Ditto. 

4  inches. 

Ditto. 

Filled  with  cerumen 

14 

M. 

40 

L. 

6  weeks. 

2  inches. 

Normal. 

Filled  with  brown,  hard  cerumen, 
hairs,  and  epithelium;  membrane 
thickened  and  detached. 

15 

F. 

46 

B. 

10  years. 

None  on  ei- 
ther side. 

Normal. 

Small,  dry,  pinkish;  no  cerumen.    . 

16 

M. 

46 

L. 

14  days. 

None. 

Normal. 

Contains  tenacious  muco-cerumenous 
discharge,  and  flakes  of  detached 
cuticle,  membrane  florid  red. 

17 

F. 

18 

L. 

2  years. 

3  inches. 

Normal. 

Filled  with  muco-purulent  dis- 
charge, containing  air  globules; 
membrane  pink. 

18 

M. 

24 

L. 

3  months. 

Normal. 

A    tumor    con- 
taining glairy 

Normal.  . 

fluid  in  helix. 

REGISTRY    OF     EAR     CASES. 


121 


State  of  MembranaTympani. 


Mottled,  red  and  white;  rough  and 
irregular  ;  thickened  ;  malleus 
not  distinguishable. 

More  polished  than  on  right ;  a  cres- 
cent of  opacity  occupies  lower  edge 

Quite  destroyed. 


Partially  thickened,  and  opaque. 


Of  a  general  pinkish  hue  :  crescen- 
tic  opacity  inferiorly  :  polished. 

Tery  red;  collapsed:  malleus  pro- 
jecting. 

Thickened,  with  red  patches.    .     , 


Thickened  and  opaque ;  collapsed. 

Thickened,  opaque,  and  reddish.  . 
On  removing  poh^pus,  membrana 

tympani  found  to  be  opaque  and 

vascular. 
Pinkish;  thickened. 

Completely  destroyed 


Thickened;  opaque:  studded  ^vith 
small  ^vhite  specks  ;  collapsed. 

Pearl-colored  ;  thickened  by  inter- 
stitial deposit ;  unpolished ;  very 
opaque  posteriorly. 

Slightly  opaque 

Deep  pink  ring  inferiorly;  dense 
white  spot  in  middle. 

Caimot  be  seen 


Collapsed ;  spotted  by  gray  patches. 
Collapsed ;     white,     thickened, 
opaque  ;  lower  edge  vascular. 
A  uniform  rose-leaf  color.     .     .     . 
Covered  by  layer  of  yellow  lymph. 


Middle  Ear 
and  Eusta- 
chian Tube. 


Pain. 


Stale  of      [Disease  attri- 
Throat.  buted  to. 


Uninflatable. 


Ditto. 

Membrane  ex- 
posed ;  deep- 
red,  smooth. 


Inflatable. 
Uninflatable. 

Inflatable. 


Uninflatable. 

Ditto. 
Inflatable. 


Lining  thicken- 
ed, red,  pulpy. 
Uninflatable. 


Xone  at  pre- 
sent. 


Inflatable. 


Ditto. 
Uninflatable. 


Inflatable. 
Uninflatable. 

Ditto. 


None. 

Ditto. 
None. 


Dull  throb- 
bing in 
tumor. 

Singing. 

Ditto. 


None. 


Buzzins 


Severe,  lan- 
cinating ; 
varies. 


None, 
Tidal. 


Singing  and 
rustling. 

Singing. 

Hissing. 


Great. 


None. 

Ditto. 

Hammering 


Normal.      Cold    and 
exposure. 


Normal.       Scarlatina. 


Tonsils  en- 
larged. 


Ulcerated. 


Normal. 


Scrofula. 


Syphilis. 


Normal.    Tailing  into 
the  sea, 


Cold    and 
draught 


Normal.    1  Scarlatina, 


Normal. 


Severe.       Falling  of  j  Membrane  '.       Cold, 
water.       red,  swollen 


Ditto. 

None. 
Slight  and 
occasional. 

'  slight.  ■ 


Loud     re-     .     .     .     . 
ports.        I 

Sawing.    |    Normal. 
None.      ;Uvula  elon- 
gated. 
Singing 


Cold. 


Normal. 


Thickened,  whitish,  succulent,  and 
vascular. 

Collapsed,  thickened,  white ;  slight- 
ly vascular ;  malleus  projecting. 

Pinkish;  spots  of  yellow  lymph  ef- 
fused on  surface. 

Pink  ;  small  aperture  in  upper  and 
posterior  part ;  air  passes  with 
squeeling  noise. 

Normal 


Inflatable. 


Slightly  infla- 
table. 


Inflatable. 


Normal. 


Boiling  and 
loud    re- 
ports. 
Loud  and 
incessant. 
Severe.     IBuzzingand 
throbbing. 


None. 


NormaL 

Normal. 
Normal. 


Nervous- 
ness, 


None. 


Auricle  hot,] 
}  and  slightly- 
painful. 


Nc 


Normal.      Scarlatina, 


NormaL 


122 


KEGISTRY    OF    EAR    CASES. 


No. 

Age. 

Ear 

Duration  of 

Hearing 

Distance. 

of 

Sex. 

— 

affec- 

of 

State  of  Auricle. 

State  of  External  Meatus  and  Canal. 

Case. 

Yrs. 

ted. 

Disease. 

19 

F. 

19 

B. 

1  year. 

Normal. 

Fibrous    tumor 
in    centre     of 

Normal 

each  lobe. 

20 

F. 

54 

L. 

4  years. 

Totiching. 

Thickened. 

Elongated  slit;  edges  collapsed; 
canal  white,  thickened,  and  con- 
tains curdy  fluid. 

21 

F. 

25 

L. 

8  months. 

Touching. 

Normal. 

Closed  by  condylomata  round  mar- 
gin; fetid  sanious  discharge. 

22 

F. 

60 

B. 

Years. 

Touching. 

Swollen,      mis- 
shapen   fiery- 
red,  with  yel- 
low crusts ;  ic- 
horous exuda- 
tion. 

Decreased  one-third ;  filled  with 
branny  scrufF. 

23 

F. 

52 

B. 

6  years. 

None. 

Hard,  thickened, 
enlarged,      its 
fossEe    obliter- 
ated; a  dusky 
brown. 

A  narrow  slit,  filled  with  crusts; 
Hning  ulcerated. 

24 

F. 

47 

R. 

Years. 

On  pressure 

Normal. 

Filled  by  mulberry-like  tumor, 
growing  from  anterior  margin, 
and  extending  into  canal. 

25 

M. 

55/ 

R! 
L. 

4  years. 
Ditto. 

None. 
2  inches. 

Normal. 
Ditto. 

Normal . 

Dry;  no  cerumen 

26 
27 

F. 

M. 

7 
11  < 

L. 
R. 

1  moath. 

2  years. 

3  inches. 
2  inches. 

Normal. 
Normal. 

Normal 

Normal 

28 

M. 

7^ 

L. 
R. 

Ditto. 
18  months. 

Ditto. 
4  inches. 

Ditto. 
Normal. 

Ditto 

Filled  with  cerumen 

L. 

Ditto. 

3  inches. 

Ditto. 

Contains  thick  caseous  discharge.    . 

R. 

Years. 

6  inches. 

Normal. 

Filled  by  discharge ;  walls  thickened. 

29 

M. 

32^ 

30 

M. 

15 

L. 
B. 

Ditto. 
9  years. 

2  feet. 
4  inches. 

Ditto. 
Normal. 

Normal 

Membrane  thickened  and  pulpy ;  a 

profuse  discharge. 

31 

M. 

9 

B. 
L. 

3  weeks. 
5  days. 

3  inches. 

4  inches. 

No  lobe. 
Normal. 

Narrowed. 

Much  narrowed 

32 

F. 

301 

I 

R. 

Uncertain. 

8  inches. 

Ditto. 

Dry  and  contracted 

33 

M. 

14 

R. 

3  years. 

4  inches. 

Normal. 

Filled  by  discharge  and  polypus.     . 

34 

M. 

38' 

R. 

3  months. 

3  inches. 

Normal. 

Normal 

35 

F. 

30  j 

L. 
R. 

Ditto. 
14  years. 

6  inches. 

None. 

Ditto. 
Normal. 

Ditto 

Normal 

L. 

Ditto. 

1  inch. 

Ditto. 

Ditto 

REGISTKY    OP    EAR    CASES. 


123 


State  of  Membrana  Tympani. 

Middle  Ear 
and  Eusta- 
chian Tube. 

Pain. 

Noise. 

State  of 
Throat. 

Disease  at- 
tributed to. 

Inflatable. 

Originally 

in  apertures 

for  ear-rings 

None. 

Occasional. 

Soreness 
and  itching. 

On  pressure 

Tumor    be- 
comes pain- 
ful   occa- 
sionally. 
Previous. 
None. 
Severe  pain 
at      night 
originally. 
Came  on 
with  pain. 
Ditto. 

None. 
Tinnitus. 
Tinnitus. 

Tinnitus. 

None. 
Ditto. 

Normal. 

Normal. 

c 

Normal. 
Normal. 

Normal. 

Normal. 
Normal. 

Piercing 
lobes. 

Cold. 

Erysipelas 
of      head 
and  face. 

White  and  thickened 

Cannot  be  seen 

Invisible,  owing  to  thickening  of 
auditory  canal. 

Cannot  be  seen.  ....... 

Densely  opaque ;  like  parchment.  . 
Thickened,  opaque,  and  collapsed. 
Pinkish  in  circumference  ;  opaque 
in  centre. 

Slightly  opaque,  but  polished.   .     . 

Pinkish  and  opaque 

White  and  thickened 

Uninflatable. 

Ditto. 

Inflatable. 

Inflatable. 
Ditto. 

Throbbing. 

Normal. 
Normal. 

Severe  cold 
day. 

Cold. 

Ditto. 

None. 
Ditto. 

Normal. 

Ditto 

Slightly  thickened ,  opaque ;  an  aper- 
ture size  of  pin's  head  anteriorly, 
filled  by  vibrating  bubble. 

Thickened ;  a  white  triangular  de- 
posit in  front  of  malleus. 

Thickened,  opaqtie,  vascular.    .     . 

Pink,  and  thickened 

Collapsed;  blood-red  superiorly.    . 

Thickened  and  opaque,   showing 
previous  disease. 

Thickened,   vascular;   large   aper- 
ture posteriorly. 

Collapsed,  dense,  white,  thickened ; 
in  centre  of  vibrating  portion  a 
clear,  thin,  depressed  spot,  with 
elevated  margin  from  previous 
ulcer;  a  pinkish  circle  inferiorly. 

Dense,    thick,    opaque,    pearly, 
dimmed. 

Thickened  and  opaque 

Red  and  thickened 

Inflatable. 
Uninflatable. 

None. 

None. 

Normal. 

A  blow  on 
the  ear. 

Inflatable. 

Inflatable. 
Inflatable. 

Uninflatable. 

None. 

None. 
None. 

Great,  like 
roaring 
of  sea. 

Tonsils  en- 
larged. 
Normal. 
Normal. 

Scarlatina. 

Scrofula. 
Occupation 
of  laundress 

Ditto. 

Cold. 

Cold     and 
pain     in 
head. 

Inflatable. 
Inflatable. 

Inflatable. 
Ditto. 

Pain  on  ac- 
cession of 
cold. 

None. 

Ditto. 

In  head. 

Previously. 

None. 

Like  steam- 
engine;  in- 
creased by 
cold. 

Ditto. 

Relaxed. 

Membrane 
red     and 
relaxed. 

Loud. 
Ditto 

Tonsils  en- 
larged. 

Scarlatina. 

124 


REGISTRY    OF    EAR    CASES. 


No. 

Age. 

Ear 

Duration 

HoEirin*'' 

of 

Sex. 

affec- 

of 

DlSt3.11CG. 

State  of  Auricle. 

State  of  External  Meatus  and  Canal. 

Case. 

Yrs. 

ted. 

Disease. 

r 

L. 

2  years. 

None. 

Normal. 

Large  firm  polypus  projecting  exter- 

36 

M. 

15^ 

nally,  cuticular  on  exposed  sur- 
face; discharge. 

^ 

R. 

Ditto. 

4  inches,  on 

Ditto. 

Discharge  ;   small  polypus  growing 

removing 
discharge. 

from  anterior  wall. 

R. 

6  months. 

1  inch. 

Normal. 

Yellow  discharge ;  large  flabby 
polypus  occupies  fundus. 

37 

F. 

19< 

l^ 

L. 
R. 

Ditto. 
2  months. 

Touching. 
2  inches. 

Very  small. 
Normal. 

Ditto 

Enlarged,  dry,  scaly,  pinkish ;  puru- 

lent discharge,  with  air  bubbles. 

38 

F. 

38^ 

L. 

Ditto. 

None. 

Ditto. 

Filled  with  caseous  deposit.  .     .     . 

39 

F. 

15 

R. 

10  years. 

Normal. 

Normal 

40 

M. 

16 

L. 

4  months. 

S  inches. 

Normal. 

Filled  by  small  polypus ;  discharge. 

41 

F. 

50 

L. 

5  years. 

Helix  obliterated 
by  pressure. 

A  mere  slit,  dry,  scaly,  plugged 
with  hard  cerumen. 

42 

F. 

30 

L, 

14  days. 

6  inches. 

Normal. 

Membrane  polished,  pink;  profuse 
discharge  began  three  days  after 
pain,  which  then  ceased. 

43 

M. 

45 

L. 

6  months. 

None. 

Normal. 

Diminished,  lower  extremity  vas- 
cular, swelling  and  pain  in  mastoid 
region. 

44 

M. 

38 

R. 

15  years. 

None. 

Normal. 

Walls  thickened,  opaque ;  discharge. 

45 

F. 

23 

R. 

5  weeks. 

None. 

Normal. 

Dry,  and  devoid  of  cerumen.      .     . 

46 

F. 

50 

B. 

3  months. 

1  foot. 

Normal. 

Filled  by  dark,  sticky  cerumen. .     . 

47 

F. 

21 

L. 

11  years. 

2  inches. 

Normal. 

Thin  mnco-purulent  discharge.  .     . 

' 

L. 

1  month. 

2  inches. 

Normal. 

Dry,  devoid  of  cerumen 

48 

M. 

20< 

R. 

3  weeks. 

6  inches. 

Ditto. 

Ditto 

> 

L. 

13  years. 

None. 

Normal. 

Dry,  membrane  pinkish  inferiorly. 

49 

M. 

17< 

^ 

R. 

Ditto. 

Touching. 

Ditto. 

Ditto 

50 

M. 

4 

L. 

Lobe     ulcerated 
from  discharge. 

Thickened,  ulcerated,  filled  with 
discharge. 

51 

F. 

44 

B. 

6  years. 

3  inches. 

Normal. 

Devoid  of  cerumen 

52 

M. 

48 

B. 

18  days. 

None. 

Normal. 

Dry,  scaly,  no  cerumen;  originally 
a  discharge  of  bloody  fluid. 

C 

R. 

20  years. 

Touching. 

Normal. 

Filled  by  condylomata ;   fetid  dis- 

53 

F. 

22] 

charge. 

( 

L. 

Ditto. 

1  inch. 

Ditto. 

Dry,  devoid  of  cerumen 

54 

M. 

7 

L. 

1  month. 

3  inches. 

Normal. 

Normal. . 

REGISTRY    OF    EAR    CASES. 


125 


Middle  Ear 

State  of  Membrana  Tj'mpaiii. 

and  Eusta- 
chian Tube. 

Pain. 

Noise. 

State  of 
Throat. 

Disease  attri- 
buted to. 

Invisible  at  time  of  note,  owing  to 

None. 

Normal. 

Scarlatina. 

size  of  polypus  and  discharge. 

Only    partially    visible ;    whitish, 

Ditto. 

thickened. 

Tolerably  clear  and  perfect.  . 

None. 

Like  bells. 

Glands    en- 

larged; the 

voice  very 

harsh. 

Ruptured  inferiorly;   reddish    gra- 
nulations growing  over  it. 

Ditto. 

Ditto. 

Vascular,  opaque,  perforated.     .     . 

Inner  wall  of 
tympanum 
seen  through 
aperture. 

None. 

Normal. 

Cold. 

Unseen 

Ditto. 

Opaque,pinkish,  perforated  in  centre. 

Bellows. 

Normal. 

Fever. 

Normal 

At  night. 
Occasion- 

None. 
Buzzing. 

Normal. 
Normal. 

Sitting      at 

Dense,  w^hite,    mottled,  somewhat 

Un  inflatable. 

pink  posteriorly. 

ally. 

open  win- 
dow. 

Highly  vascular,    perforated    infe- 

Inflatable; 

Originally 

Tinnitus  in 

Normal. 

Cold  and  ex- 

riorly. 

membrane 

violent  at 

ear  and 

posure. 

pinkish. 

night. 

head. 

Of  a  uniform  pinkish  tint.     .     .     . 

Uninflatable. 

Severe, 

Frying  and 

Normal. 

Suppressed 

with  pul- 

buzzing. 

perspira- 

♦ 

sation. 

tion. 

Thickened,  opaque,  has  lost  polish. 

Uninflatable. 

None. 

Tinnitus. 

Normal. 

Very  opaque,  thickened  posteriorly, 

Inflatable. 

Much  at 

Beating  in 

Normal. 

Sleeping  in 

pinkish  anteriorly. 

night. 

ear  and 
head. 

wet  clothes. 

Collapsed ;  a  dense  white  crescent 

Uninflatable. 

None. 

Singing. 

Normal. 

inferiorly. 

Red  and  granular 

Severe. 

None. 

Normal. 

Covered  with  red  vessels ;  malleus 

Slight,    in- 

Tidal. 

Normal. 

Heats  and 

scarcely     discernible  ;     its     site 

creased  on 

colds. 

marked  by  an  opaque  line. 

sneezing. 

A  florid  red 

Ditto. 
Occasion- 

Ditto. 
Like  water- 

Opaque, thickened,  irregularly  spot- 

Eustachian 

Normal. 

Fever. 

ted,  vascular  superiorly. 

tubes  free;  air 
has   a  whist- 
ling sound. 

ally  vio- 
lent. 

fall. 

A  pale  pink  over  outline  of  malleus. 

Whistling 
sound. 

Ditto. 

Ditto. 

Thickened,  vascular,  perforate    at 

Mucous     dis- 

Originally. 

None. 

Normal. 

inferior  edge. 

charge  from. 

Thickened   and   opaque,   vascular 

Only  occasion- 

Occasion- 

Buzzing and 

Normal. 

ally  pervious 
to  air. 

ally. 

beating. 

Dark  red,  thickened,  dry 

Violent. 

Buzzing. 

Normal. 

Wet  and 
cold. 

Invisible 

None. 

Normal. 

Collapsed ;  defined,  crescentic  opa- 

city inferiorly. 

Uniform  pink  color 

Inflatable. 

None. 

None. 

Normal. 

Cold. 

126 


REGISTRY    OF    EAR    CASES. 


No. 

of 

Case. 


Sex. 


Age. 
Yrs. 


Ear 

affec' 
ted. 


Duration 

of 
Disease. 


Hearing 
Distance. 


State  of  Auricle. 


State  of  External  Meatus  and  Canal. 
Dry,  no  cerumen 

Dry  and  scaly 

Dry . 

Filled  with  honey-like  cerumen.     . 
Mucous  secretion,  containing  air  glo- 
bules. 

Dry. 

Dry  and  white 

Ditto 

Contracted,  walls  thickened ;  filled 
with  crusts  of  inspissated  mucus; 
has  occasional  discharge. 


Membrane   thickened  and  pulpy; 
profuse  discharge. 

Normal 

Normal . 

Pinkish  at  lower  extremity.  .     .     . 


55 


56 
57 


58 


59 


R. 


For  years. 


M 
F. 

M. 


25- 


12  ; 
50 


40 


20- 


60 


61 
62 


63 


64 
65 


66 

67 
68 
69 


70 


71 

72 


M. 


F. 

M. 


16^ 


14 


50 


M. 
F. 

M. 

M. 
F. 
F. 

M. 

F. 
F. 


25< 


25 


40 


14 
50 


16 


21 
)0 


3  months. 
Ditto. 


3  inches. 


5  inches. 
4  inches. 
Normal. 


1  month. 


Many  years, 

Ditto. 
3  years. 


Ditto. 

3  months. 
2  weeks. 
6  months. 


2  weeks. 
2  years. 


10  years. 
Ditto. 

Many  years. 


8  months. 


10  years. 

10  years. 
14  years. 


None. 


4  inches. 


2  inches. 


Impaired 
after  fits. 
6  inches. 

Touching. 


Ditto. 

Touching. 
None. 


None. 
3  inches. 


Normal. 


Ditto. 
Normal. 
Ditto. 
Hard,    elevated, 
sensitive   cica- 
trices on  helix. 
Normal. 


Normal. 

Ditto. 
Normal. 


Touching 

None. 


Touching 

None. 


Ditto. 

Normal. 
Normal. 
Normal. 

Ditto. 

Normal. 
Normal. 


Normal. 
Ditto. 

Normal. 
Helix  wanting. 
Flattened  by  long 
pressure  of  a 
band  ;  helix 
obliterated. 
Normal. 

Normal. 
Normal. 


Impacted  with  cerumen ;  the  cuticle 
of  canal  and  membrana  tympani 
removed  with  it. 

Filled  with  hard  cerumen.     .     .     . 

Coated  with  discharge. 


Dry,  devoid  of  cerumen 

Ditto 

Dry 

Only  size  of  crow-quill 

Walls,  touch  resembling  a  slit;  lin- 
ing white,  thickened,  exuding  dis 
charge ;  bottom  filled  with  hard 
cerumen. 

Walls  white,  thickened ;  coated 
with  discharge. 

Filled  by  discharge;  granular  polypus. 

Dry,  devoid  of  cerumen 


REaiSTRY    OF    EAR    CASES. 


127 


State  of  Membrana  Tympani. 


Middle  Ear 
and  Eusta- 
chian Tube. 


Pain. 


Noise. 


State  of 
Throat. 


Bisease  attri- 
buted to. 


Thickened,  opaque ;  atheromatous 
deposit,  of  crescent  shape  poste- 
riorly ;  mottled  anteriorly ;  polished. 

Thickened  and  opaque 

Thickened,  collapsed,  pinkish.  .     . 

Normal 

Thickened,  vascular;  large  aper- 
ture anteriorly. 

Rather  opaque,  dim;  a  cicatrix  in 
anterior  part  running  from  above 
downwards,  which  becomes  red 
on  inflation  ;  had  hemorrhage 
from  ear  after  fall. 

Slightly  collapsed;  centre  natural; 
dense  white  opacity,  with  defined 
edge  round  inferior  circumference. 

Similar  to  left,  but  thin,  and  of  a 
skim-milk  color. 

Thickened;  one-half  destroyed  in- 
feriorly. 


Almost  entirely  destroyed ;  a  thick 
^vhite  patch  containing  malleus 
above. 

Slightly  thickened  on  both  sides.   . 


Uninflatable. 


Ditto. 


None. 


Ditto. 
None. 


Like  car- 
rias:es. 


Ditto. 
Occasional. 


Normal. 


Normal. 


Cold. 


Inflatable. 


Normal. 


Inflatable. 


Inflatable. 

Memb.  pulpy 
and  florid  red; 
aircannotpa; 
into  tympa- 
num ;  tryinc 
to  inflate  red 
dens  memb. 
Ditto. 


Occasion- 
ally. 


Occasional- 
ly severe. 

Ditto. 

None. 


Ditto. 


Incessant 
like  steam- 
engine. 


Normal. 


Normal. 


Great  and 
continuous 
A  rare  case 


Ditto. 


Normal. 


Rough,  florid  red,  granular. 


Pinkish,  with  crescentic  opacity  at 
lower  edge ;  polished. 

Slightly  vascular;  thickened, 
opaque. 

White,  thickened ;  pulpy  from  pres- 
sure. 
Quite  destroyed 


Inflatable;  in- 
creasing color 
in  M.  T. 
Uninflatable. 


Lacerating. 
Intermitting 


Blowinj; 
None. 


Normal. 
Normal. 
Normal. 


Uniformly  opaque ;  white,  thick.   . 
Thickened,  opaque  ;  skim-milk  co- 
lor. 

Thickened  and  opaque 

Only  partially  visible 

Dense  white,  mottled  with  pink.  . 


None  at  pre- 
.    sent. 

None. 
Ditto. 


Buzzins 


Tinnitus. 
Ditto. 


Normal. 
Normal. 

Normal. 


Pain. 
Occasional. 


Buzzing. 


Normal. 
Normal. 
Normal. 


Fall  on  back 
of  head, 
against 
street  rail 


Fall  on  her 

head. 
Cold  and 

exposure 


Influenza. 

Scarlatina ; 
glandular 
swellings. 


A  cold 
draught. 


Pulpy,  thickened,  white. 


Uninflatable. 


Normal. 


Unseen 

Much  collapsed,  thickened,  opaque. 


Uninflatable. 


None. 
Loud,  tidal, 


Normal. 
Normal. 


128 


REGISTRY    OF    EAR     CASES. 


No. 

of 

Case. 


Sex. 


Age. 
Yrs. 


Ear 
affec- 
ted. 


Duration  of 
Disease. 


Hearing' 
Distance. 


State  of  Auricle. 


State  of  External  Meatus  and  Canal. 


73 


74 


75 
76 


77 
78 

79 

80 


82 
83 


84 
85 
86 


87 


90 
91 

92 

93 
94 


M. 

M. 
M. 


20 


45 


M. 
M. 

F. 

M. 

M. 

M. 
F. 

M. 
F. 
M. 


23j 


M. 

F. 

M. 
F. 


M. 
F. 


61 


J. 


19 


12 
22 

r 

I 
37-{ 

15 
15 


4  months. 


A  few  days 

4  years. 
1  year. 


9  years. 
9  weeks. 


1  month. 
3  years. 


2  years. 


5  months. 
1  year. 

6  months. 


4  years. 

1  month. 
4  years. 
1  year. 

Years. 

4  months. 
1  year. 


4  years. 
3  years. 


11  years. 

Ditto. 
9  years. 

Ditto. 


4  inches. 
2  inches. 


3  inches. 


Touching. 
4  inches. 


8  inches. 
Touching. 


3  feet. 


1  inch. 


Touching, 

None. 
Touching. 

2  inches. 


4  inches. 

4  inches. 

6  inches. 

None. 


Touching. 

Ditto. 
4  inches. 

6  inches. 

3  inches. 

3  inches. 

2  inches. 

4  inches. 
Touching. 


Ditto. 

1  incli. 

Touching. 

None. 
Touching. 


Normal. 
Ditto. 

Normal. 

Normal. 
Normal. 


Normal, 
Normal. 

Ditto. 

Eczematous. 
Normal. 


Ditto. 

Normal. 

Ditto. 

Normal. 

Thickened,  red, 

eczematous. 

Normal. 
Normal. 


Normal. 

Normal. 

Ditto. 
Normal. 

Ditto. 

Normal. 
Normal. 

No  conch  or  lobe 

Normal. 

Normal. 


Ditto. 

Normal. 

Ditto. 
Normal. 

Ditto. 


Epithelium  thickened,  peeling  off; 
yellow  mucous  discharge. 

Filled  with  caseous  matter ;  mem- 
brane white  and  pulpy. 


Impacted  with  dark  cerumen,  epi- 
thelial scales,  and  hairs. 
Dry,  and  devoid  of  cerumen. .     .     . 
Dry  and  scaly;  no  cerumen.   .     .     . 


Scaly;  mottled  by  specks  of  blood.  . 
Elliptical,  dry,  scaly,  florid  pink.     . 

Dry,  elliptical, — apparently  congeni- 
tal. 

Covered  with  whitish  exudation.    . 

Dry,  scaly ;  had  discharge  for  a  month 
after  first  attack. 


Dry  and  scaly;  no  cerumen.  .     .     . 

Devoid  of  cerumen 

Normal 

Discharge,  from  sudden  burst.     .     . 
Filled  by  cerumen,  limiting  extent 
of  eczema. 

Filled  by  cerumen 

Filled  by  pitch-like  wax 

Honey-like  wax  pours  out.      .     .     . 

Florid  red;  bony  protuberance  at- 
tached anteriorly;  discharge;  had 
polypus  two  years  ago. 

Long  and  tortuous,  devoid  of  ceru- 
men, white,  polished. 

Ditto 

Normal.  .     .     < 

Ditto 

Normal 

Dry;  devoid  of  cerumen 

Normal 

Normal 

Scaly ;  no  cerumen 

Scaly ;  contracted  from  exostosis. 

Dry;  lining  pink 

Filled  with  cerumen 

Dry;  no  cerumen 

Ditto 


REGISTRY     OF    EAR     CASES. 


129 


State  of  MembranaTympani. 


Collapsed,  thickened,  pink;  small 

slit  posteriorly ;  air  whistles  through. 

Much  collapsed ;  dense  white ;  trian- 
gular aperture  anteriorly,  with  in- 
dented edges;  red  membrane  of 
middle  ear  seen  through. 

External  layer  white,  thickened, 
pulpy  adherent  to  cerumen. 

Normal 

Collapsed;  slightly  thickened ;  mot- 
tled with  white  spots;  vascular 
above  malleus. 

Red  patch  in  front  of  malleus.  .     . 

Uniform  dark  red ;  malleus  imper- 
ceptible. 

Collapsed,  thickened,  opaque ;  mal- 
leus very  prominent. 

Covered  with  whitish  exudation.   . 

Collapsed,  thickened,  opaque; 
slightly  pinkish;  dense  yellow  spot 
before  malleus. 


Polished,  pink 

Pink,  but  polished 

Thickened,  opaque,  vascular  supe- 
riorily. 

Florid  red, 

Slightly  opalescent, 


Surface  red,  pulpy. .     . 
Vascular  from  offending 

Normal 

Totally  removed.     .     . 


body. 


Thickened,  opaque,  pinkish  crescent 
inferiorly;  malleus  prominent. 

Collapsed,  unpolished,  white  above, 
red  below  ;  malleus  prominent. 

Pinkish  spot  anteriorly,  thin,  trans- 
parent, projecting  like  elastic  mem- 
brane in  ulcer  of  cornea. 

Thickened,  vascular ;  aperture  near 
point  of  malleus. 

Collapsed,  red,  thickened.     . 

Thickened,  opaque;  several  vascular 

elevations;pink  crescent  inferiorily. 

Pink  and  thickened 

Thickened,  opaque,  pearl-colored. 

Collapsed,  unpolished;  malleus 
prominent;  yellow,  atheromatous 
deposit  inferiorly. 

Collapsed;  white  spot  in  centre.    . 

Pink ;  aperture  posteriorly.    .     .     . 

White  and  pulpy 

A  uniform  dense  white 

Opaque;  like  skimmed  milk.     . 


Middle  Ear 
and  Eusta- 
chian Tube. 


Inflatable. 
Ditto. 


Pain. 


Uninflatable. 


Insuppuratifcn. 
Uninflatable. 


Inflatable;  red- 
ness of  M.  T. 
increased;  re- 
port on  inflat. 
Inflatable. 
Inflatable. 
Ditto. 


Inflatable. 


Inflatable. 


Promontory 
plainly  seen. 

Inflatable. 

Uninflatable. 

Inflatable ;  in- 
creases   pro- 
jection. 
Inflatable. 


Inflatable. 
Uninflatable. 

Inflatable. 

Inflatable. 

Uninflatable. 


Ditto. 

Mem.  villous, 


Numb. 
None. 


Pains  in 
head. 
In  head. 

None. 


Pain. 

Great. 


None. 


Loud    and 

continuous. 

Bellows. 


Severe ;  ver- 
tigo. 

Buzzing. 
Blowing ; 
giddiness. 

Stuffing. 
Throbbing. 


Pain    and 

soreness. 


Soreness. 
Originally. 


Rheumatic. 
Soreness 
and  itchi- 
ness. 
Pain. 
None. 
Ditto. 
None. 


Slight. 

None. 

Originally. 


None. 
None. 


None. 
None. 


Ditto. 

None. 
Ditto. 
None. 


Whi 


Buzzing 


Buzzing. 

A  grating 

Ditto. 


State  of 
Throat. 


Disease  attri- 
buted to. 


Normal. 


Normal. 

Normal. 
Normal. 


Normal. 
Normal. 


Normal. 
Normal. 


Relaxed,red 

Normal 


Sudden  cold 


Headache. 


Cold. 


Cold. 


Hammering 


Buzzing 
Singing 

Ditto. 

None. 


Tinnitus. 

Ditto. 
Bellows. 


None. 


Tinnitus. 
None. 

Tinnitus. 
Tinnitus. 
Waterfall. 


Ditto. 
Ticking. 
Singing. 


Normal. 


Normal. 
Normal. 


Normal. 


Normal. 


Normal. 


Normal. 
Normal. 

Ditto. 
Normal. 
Normal. 


C.  tonsillitis. 


Normal. 


Cold. 
Scarlatina. 


Diving  in 
the  sea. 

Cold. 


Cold. 


Typhus  fe- 
ver. 


Influenza. 


Cold. 


Measles. 


130 


REGISTRY    OF    EAR    CASES. 


No. 

of 

Case. 

Sex. 

Age. 
Yrs. 

Ear 
affec- 
ted. 

Duration  of 
Disease. 

Hearing 
Distance. 

Stale  of  Auricle. 

State  of  External  Meatus  and  Canal. 

95 

F. 

25 

B. 
L. 

4  months. 
1  month. 

1  inch. 
Touching. 

Normal. 
Normal. 

Dry  and  scaly 

Pink,  moist,  some  cerumen  inferiorly 

96 

M. 

16<j 

> 

R. 
R. 

2  months. 
2  years. 

Ditto. 

None. 

Ditto. 
Normal. 

Pink 

Filled  by  yellow,  bloody  discharge. 

97 

F. 

1< 

98 
99 

F. 

M. 

»{ 

7 

T, 

None. 
2  inches. 

1  inch. 
4  inches. 

Ditto. 
Normal. 

Ditto. 
Normal. 

Filled  by  inspissated  discharge. 
Normal 

R. 

L. 
K 

3  months. 

3  years. 
Years. 
Ditto. 

Ditto 

Normal 

100 

M. 

4oJ 

R. 
L. 

None. 
None. 

• 
Normal. 

Ditto. 

Filled  by  caseous  matter,  containing 

air  globules. 
Filled  by  thick  discharge 

37^ 

L. 

12  years. 

None. 

Normal. 

Enlarged,  dry,  pinkish ;  no  cerumen. 

101 

M. 

.. 

R. 

Ditto. 

3  feet. 

Ditto. 

Dry,  scaly ;  normal  in  color.   .     .     . 

102 
103 
104 

M. 
M. 
F. 

62 
14<^ 
30  J 

R. 
R. 

L. 
L. 

R. 

Since  child- 
hood. 
4  years. 

Ditto. 
9  years. 

Ditto. 

None. 

3  inches,  in- 
creased by 
discharge. 
1  inch. 
None. 

Touching. 

Normal. 
Normal. 

Ditto. 
Normal. 

Ditto. 

Coated  with  discharge 

Coated  with  fetid  discharge.  .     .     . 

Normal 

Normal 

Filled  with  cerumen 

105 
106 

F. 
F. 

•1 

25 

L. 
R. 
L. 

6  months. 
14  days. 

None. 

1  inch. 

2  inches. 

Normal. 

Ditto. 
Normal. 

Filled  with  cerumen 

Normal 

Dry ;  no  cerumen 

107 
108 

F. 

M. 

10 
21 

R. 
R. 
R. 

5  years. 
10  years. 

1  inch. 

None. 

2  inches. 

Normal. 
Normal. 
Normal. 

Normal.  .     .■ 

Normal 

Dry,  pinkish ;  no  cerumen.     .     .     . 

109 

F. 

151 

110 
HI 

F. 
F. 

4 
50-] 

L. 
L. 
R. 

2  years. 
1  year. 
7  years. 

Touching. 

6  inches. 

1  inch. 

Ditto. 
Normal. 
Normal. 

Coated  with  discharge,  which  inter- 
mits. 

Filled  by  sanious  discharge ;  small 
polyyus  attached  posteriorly. 

No  cerumen 

112 

F. 

20 

L. 
R. 

Years. 

Ditto. 
1  inch. 

Ditto. 
Normal. 

Normal 

White,  polished;  no  cerumen.    .     . 

113 

F. 

12 

R. 

4  years. 

Touching. 

Normal. 

No  cerumen;  pinkish 

EEGISTET     OF     EAR     CASES. 


131 


Middle   Ear 

State  of  Membrana  Tj-mpani. 

and  Eusta- 
chian Tube. 

Pain. 

Xoise. 

State  of 
Throat. 

Disease  attri- 
buted to. 

Tliickened;  streaked  with  red. 

Inflatable. 

None. 

Tidal. 

Normal. 

Cold. 

Pink;  deep  red  crescent  inferiorly: 

Inflatable;  in- 

Dull. 

Bellows. 

Normal. 

several  scarlet  vessels  on  surface 

creasing  red- 

radiating from  point  of  malleus. 

ness. 

A  uniform  light  pink 

Ditto. 

Ditto. 

Ditto. 

. 

Completely  removed 

White  bubble 

Great  origi- 

Normal. 

Scarlatina ; 

in    Eustach. 

nally. 

I 

facial  pa- 

opening. 

ralysis.. 

Flat,  thickened;  red  and  yellow  spots 

Red. 

Opaque;  pinkish  inferiorly;  bulged 

Inflatable. 

None. 

None. 

Normal. 

outwards  in  pockets. 

Thickened  and  white  throughout. . 
Thickened,  opaque;    like  muffed 

glass. 
Thickened,  opaqtxe;  small  aperture 

Uninflatable. 

Ditto. 

Ditto. 

None. 

None. 

Normal. 

Inflatable. 

Pain. 

None. 

Normal. 

opposite  Eustachian  opening. 

Quite  destroyed 

Memb.  thick; 
exuding  blood. 

None. 

None. 

Unpolished;     generally     opaque. 

Inflatable. 

Slight    at 

Noise    in- 

Normal. 

Draught  of 

with   pink    dots;    malleus   pro- 

present. 

creased 

cold  air. 

jecting,  marked  by  white  line. 

by  cold. 

Clear  in  centre;  white  crescent  in- 
feriorly. 

Ditto. 

None. 

None. 

Opaque,  thickened,  and  granular. . 

Uninflatable. 

None. 

Normal. 

White ;  thickened  posteriorly ;  vas- 

Inflatable. 

None. 

Singing. 

Normal. 

Cold. 

cular  anteriorly,  with  small  val- 

vular aperture. 

A  dark-red  color.     ...... 

Thickened,  opaque,  dense  white.  . 

Ditto. 
Inflatable. 

Pain. 

Chirping. 

Normal. 

Cold    after 

parttirition. 

White,  thickened ;  slightly  vascular, 
probably  from  removing  cerumen. 

Thickened,  opaque,  bluish  white. . 

Inflatable. 

None. 

Tidal. 

Normal. 

Cold. 

Ditto r 

Ditto. 
Inflatable;  vas- 

Pain   in- 

Loudreports 

Normal. 

Ditto. 
Wet  feet. 

Vascular,    wrinkled;     a    uniform 

pink  color. 

cularity  of  M. 
T.  increased. 

creased 
at  night. 

Rose-colored,  deepening  in  centre. 

Inflatable. 

None. 

None. 

Normal. 

polished. 

Normal 

Inflatable. 

Deep-seated 

Normal. 

Paralysis  of 
face ;  ptosis. 

Opaque,  pink;  aperture  in  centre, 

Mem.  deep 

None. 

None. 

Normal. 

Fever. 

with  white,  thickened  edge;  mal- 

red;  shadow 

leus  drawn  upwards  and  back- 

from edge  of 

wards. 

rent. 

Very  opaque,  with  red  spot  in  cen- 

Severe. 

Tinnitus. 

Bathing. 

tre  ;  malleus  not  discernible. 

Invisible 

None. 
Flowing  of 

Normal. 

Scarlatina. 
Head 

Collapsed,  thickened ,  irregular  on 

Uninflatable. 

In  ears  and 

surface;  yellow  inferiorly;  whit- 

head. 

water. 

shaved. 

ish  above. 

Dense,  yellow,  irregular;  dark  de- 

Inflatable; 

Pain  origi- 

Boiling. 

Normal. 

Ditto. 

posit    posteriorly;    white    streak 

M.T.  projects 

nally. 

falls  from  malleus.                           |  in  pouches. 

Large  aperture  anteriorly ;  its  edge 

1  Uninflatable: 

Buzzing. 

Normal. 

Scarlatina. 

white,  thickened,  inverted. 

1  rose-colored. 

Thickened,  pink,  and  white.     .     . 

Slightly  infl. 

None. 

Ringing. 

Normal. 

132 


REGISTRY    OF    EAR    CASES. 


No. 

of 

Case. 


114 
115 


116 


117 


118 


119 


120 


121 


122 


123 


124 


125 


126 


127 


Sex. 


Yrs 


21 
12 

42  i 


50- 


Ear 

affeC' 
ted. 


Duration  of 
Disease. 


1  year. 


Hearing' 
Distance. 


6  months. 
18  months. 


F. 

25) 

F. 

16  J 

F. 

12) 

r 

F. 

30<| 

■^ 

F. 

22J 

M. 

50 

r 

M. 

18^ 

I 

F. 

30  < 

M. 

18<j 

6  months. 


2  inches. 

Touching 
'2  inches. 

None. 


Totiching. 
Touching. 


4  inches. 
2  inches. 

None. 

2  inches. 

1  inch. 

2  inches. 
4  inches. 

^  inch. 

6  inches. 

Touching. 


Ditto. 

4  inches. 


6  inches. 

None. 
None. 


14  inches. 
Touching. 


None. 
2  months.       3  inches. 


L. 

L. 

Years. 

E 

R. 

1  month. 

L, 

10  years. 

R. 

6  weeks. 

T, 

R. 

5  years. 

T, 

R. 

3  years. 

L. 

L. 

6  years. 

R. 

•     •     ■     • 

R. 

20  years. 

R. 

9  years. 

L. 

1  year. 

L. 

10  years. 

State  of  Auricle. 


R Touch 


Protuberance  in 

front  of  tragus. 

Normal. 

Normal. 

Normal. 


Ditto. 
Normal. 


Ditto. 
Normal. 

Ditto. 

Normal. 

Ditto. 

Normal. 
Ditto. 

Normal. 

Ditto. 

Normal. 


Ditta 

Normal. 
Normal. 


Ditto. 
Normal. 

Ditto. 
Normal. 


Ditto. 


State  of  External  Meatus  and  Canal. 


Filled  with  muco-purulent  discharge. 

Small  polypus  attached  anteriorly.  . 
Filled  by  abscess  spreading  under 

tragus. 
Moist,  polished 


Ditto.  Ditto.  . 

Normal.  Normal. 


Ditto.  .   ■ 

Very  large ;  lining  normal,  but  dry. 


Ditto. 


Dry,  scaly,  containing  crusts  of  in- 
spissated discharge,  which  ceased 
lately. 


Coated  with  a  thin  discharge. 

Normal 

Dhto 


Normal. 
Ditto.  . 


Had  discharge  on  three  occasions.  . 

Ditto.  .     .  ' .     .     . 

Dry,  devoid  of  cerumen 


Ditto. 


Impacted  with  hard  cerumen.    .     . 

Dry  and  scaly;  had  discharge  until 
two  years  ago. 


Dry,  red  ;  no  cermnen.  . 
Dry ;  membrane  pinkish. 


Dry.    .     .     . 

Dry  and  scaly. 


Ditto. 


REGISTRY    OF    EAR    CASES. 


133 


State  of  Membraiia  Tympani. 


Middle  Ear 
and  Eusta- 
chian Tube. 


Noise. 


State  of 
Throat. 


Disease  at- 
tributed to. 


White  ;  much  thickened  and  col- 
lapsed. 

Ditto 

Invisible 


None. 


Tinnitus. 


Normal. 


Lower  anterior  half  destroyed,  re- 
mainder thickened,  drawn  tap 
with  malleus. 


Ditto 

Like  muffed  glass ;  zone  of  pinkish 
vascularity  inferiorly  ;  dense  white 
band  between  point  of  malleus 
and  anterior  edge. 
Nearly  as  right,  but  collapsed,  want- 
ing white  band. 
Lo^ver  anterior  half  destroyed;  mal- 
leus, with  a  fragment  of  thick- 
ened membrane,  drawn  upwards 
and  backwards. 

Vascular,  opaque;   small  opening 

anteriorly. 
Thickened,  opaque,  mottled  with 

pink. 
Uniform  pink,  deepening  inferiorly; 

unpolished. 
Opaque,  skim-milk  color.       .     .     . 
Collapsed ;  dense  ;  red  vessels  over 

malleus. 
Thickened,  opaque,  like  crumpled 

parcluuent. 
Unpolished,  brownish  red,  with  cres- 
cent of  vascularity  at  inferior  edge. 
Collapsed,  opaque,    dull ;    an   ele- 
vated cicatrix  in   lower  anterior 

portion. 


Lif ;  M.  deep 
red,  shining; 
air  causes 
squeeling 
sound. 

Ditto. 
Uninflatable, 


Ditto. 

Membrane 
red,pu]py;  sha- 
dow  thrown 
by  fragment 
of  mem.  tym. 
Membrane 
villous,  red. 
Lifiatable. 


Inflatable. 
Uninflatable. 

Uninflatable. 

Inflatable. 


Slightly  opaque,  bttt  polished.   .     . 

Opaque ;  irregular  on  surface  by 
number  of  concavities  and  con- 
vexities. 

White  round  circumference ;  a 
bright,  clear  spot  in  centre  ;  its 
edge  well  defined. 

Collapsed,  opaque,  like  old  parch- 
ment; a  red  streak  over  malleus. 

Collapsed,  polished,  reflecting  light 
from  several  small  depressions ; 
malleus  very  prominent,  a  pinkish 
hue  over  site  of  its  attachment. 

Opaque,  polished,  made  red  by  infl. 

Collapsed,  skim-milk  color ;  white 
band  depends  from  malleus. 

Thickened,  mottled  with  white.     . 

Pink,  mottled  with  white;  light  re- 
flected from  irregularities  on  sur- 
face. 

Highly  vascular,  but  polished.  .     . 


Uninflatable. 

Inflatable ;  can 
press  out  spot 
in  mem.  tym. 


Uninflatable. 


Inflatable. 
Uninflatable. 

Ditto. 
Inflatable. 


Ditto. 


Originally. 

Originally 
at  night. 


None. 

Ditto. 
None. 

Ditto. 
On  sneezini 


Ditto. 
Pumping. 

None. 


Normal. 
Normal. 


Cold. 


None. 
Ditto. 

Pain  origi- 
nally. 


Great. 


None. 
Acute  ori- 
ginally. 


Much    for- 
merly. 


None. 

None. 
On  first  ac- 
cession. 

Ditto. 


Ditto. 
Singina 


Tinnitus, 
(rare). 


Singinc 
Ditto. 


None. 
Ditto. 


Like     run- 
ning water 


Ditto. 

A  ticking. 


Ditto. 


None. 
Tinnitus. 


Ditto. 
Boiling  wa- 
ter. 
Ditto. 
Beating  ori- 
ginally. 


Normal. 


Normal. 


Memb.  red, 
swollen 
Normal. 


Normal. 


Normal. 


Normal. 


Normal. 
Normal. 


Ditto. 


Normal. 
Normal. 


Cold. 


Blow  fol- 
lowed by 
hemorrhage 
from  R.  ear. 


A  severe 
wetting. 


Parturition. 


REaiSTRY    OF    EAR    CASES. 


No. 
of 

Case. 


Sex. 


Age.  Ear 
—  afFec- 
Yrs.    ted. 


Duration  of 

of 

Disease. 


Hearing 
Distance. 


State  of  Auricle. 


State  of  External  Meatus  and  Canal. 


128 

129 

130 
131 

132 
133 

134 


135 

136 
137 

138 

139 

140 

141 

142 

143 

144 

145 

146 

147 
148 

149 
150 

151 

152 
153 

154 
155 


F. 

F. 

M. 
F. 

M. 

M. 


M. 

F. 
M. 

F. 

M. 

F. 

F. 

F. 

M. 

M. 
F. 

M. 

M. 
M. 

F. 
F. 

F. 

M. 

M. 

F. 
F. 


25 


10^ 

I 
21 

29 

42 
45 
26 
30 

20^ 

33) 

30 
21 

50  J 

20 
50 

28  j 
18  ^ 

\ 

22^ 
I 
I 

30  J 
25 

29) 
19| 


2  years. 
6  years. 


3  months. 
6  months. 


3  years. 
18  years. 


4  years. 


17  days. 
Uncertain. 

14  days. 

2  months. 
4  years. 
3  weeks. 

15  years. 
Ditto. 

8  weeks. 

Ditto. 

7  years. 

1  week. 

3  weeks. 

Ditto. 

4  years. 

12  months. 

8  montlis. 


Normal. 
Touching 


Ditto. 
4  inches 


3  years. 
Ditto. 
From  child- 
hood. 

Ditto. 

5  years. 

Ditto. 

3  months. 

From  in- 
fancy. 
Ditto. 

10  days. 
Uncertain. 


Touching. 
3  inches. 

None. 
Touching. 

8  inches. 

None. 


1  inch. 
Touching. 
2  inches. 

Touching. 

None. 
2  inches. 

1  inch. 

4  inches. 
6  inches. 

Touching. 

None. 

None. 

None. 

1  inch. 

None. 

None. 
6  inches. 
Touching, 

4  feet. 

5  inches. 
10  inches. 
2  inches. 


None. 

None. 

Touching, 

2  inches. 

1  foot. 

Ditto. 

3  inches. 
2  inches. 


Eczematous. 
Normal. 

Ditto. 

Normal. 

Eczematous 

from  discharge, 

Normal. 

Normal. 

Dhto. 
Normal. 

Ditto. 

Normal. 


Ditto. 

Normal. 
Normal. 

Flattened  by 
pressure. 
Normal, 

Normal. 

Normal. 

Normal. 
Ditto. 

Normal ;     very 
mobile. 

Ditto. 

Eczematous. 

Inflamed. 

Normal. 

Ditto. 

Excoriated. 

Normal. 

Normal. 

Ditto. 
Normal. 

Ditto. 
Normal. 


Ditto. 

Normal. 

Ditto. 

Normal. 

Normal. 

Ditto. 

Normal. 

Ditto 


Scaly  eruption  extending  into  meatus. 
Filled  by  discharge ;  small  polypus 
from  upper  wall ;  lower  edge  ulcer'd. 
Coated  with  discharge  and  crusts.   . 

Dry,  shining,  vascular 

Enlarged ;  filled  with  ichorous  dis- 
charge; memb.  white  and  thickened. 

Filled  with  oily  fluid 

Normal 

A  scale  of  dark  cerumen  at  bottom. 
Enlarged ;  covered  with  discharge  ; 

polypus,  attached  anteriorly. 
Dry;  had  discharge  previously.  .     . 

Normal 

Ditto 

Florid  red  ;  cuticle  peeling.     .     . 
Red  ;  cuticle  abraded 

Contracted ;  coated  with  discharge. . 

Thickened;  lining  membrane  whitish 

Normal 

Normal 

Dry ;  discharge  until  three  years  ago. 
Coated  by  slight  discharge.     .     .     . 

Dry ;  devoid  of  cerumen 

Dry,  white,  unpolished 

Normal 

Cuticle  thickened  ;  discharge.       .     . 

Filled  with  cerumen 

Dry,  pink;  no  cerumen 

Filled  with  discharge 

White  ;  small  exostosis  anteriorly.  . 
Thickened ;  bloody  discharge. 

Dry;  no  cerumen 

Normal 

Dry ;  no  cerumen 

Coated  with  thin  discharge,  which 
intermits. 

Dry,  crusty 

Lining  thickened;  dry,  red.     .     . 
Filled  by  purulent  discharge.      .     . 
Normal 

Lining  pink ;  polished 

Ditto 

Long  and  tortuous;  dry 

Narrow  and  elliptical 


REGISTRY     OF     EAR     CASES. 


135 


State  of  Membrana  Tympani. 


Middle  Ear 
and  Eusta- 
chian Tube. 


Noise. 


State  of       Disease  attri- 
Throat.  buted  to. 


Slightly  thickened, white,  but  polish'd 
Unseen 


Inflatable. 


Covered  with  scaly  incrustation,    . 

Flat;  an  uniform  sheet  of  opacity. 

White,  perforate ;  air  globule  reflects 

light  at  antero-inferior  portion. 

Thickened,  dense,  red 

Opaque,  pinkish,  vascular.    . 
Depressed  red  spots,  probably  ulcers 
Unseen 


Inflat.;  water 
passes  through 

Inflatable. 

Inflatable. 

Inflatable. 


Dim ;  crossed  by  white  band :  a  de- 
pressed spot  superiorly. 

Much  thickened  ;  a  large  aperture 
posteriorly. 

Thickened,  opaque,  vascular.  .  . 
Dense ;  red ;  bulged  outwards.  .  . 
A  florid  red;  malleus  unseen.    .     . 


Uninflatable. 

Promontory 
presents  at 
aperture. 

Uninflatable. 

Gurgl.  sound. 


Whitish,  succulent. 


Opaque ;  streaked  with  bright  red 
vessels.     Fecial  Paralysis. 

Collapsed;  traversed  by  pearl- 
colored  band. 

Thickened  below;  bright  pink  above 

Granular,  like  conjunctiva  of  eyelid. 

Fleshy;  bulged  into  meatus;  dis- 
charge from. 

Collapsed,  opaque  above,  pink  be- 
low, white  behind. 

White;  yellow  deposit  in  centre.    . 

Normal 

Unseen;  ruptured 

Thickened ;  red  over  malleus.  . 

Pink,  with  vesicular  projections.    . 

Granular,  like  ripe  raspberry.    .     . 

Opalescent ;  white  ring  inferiorly. . 

Three  parts  removed 

Thickened,  peralaceous 

Pink,  mottled  with  white.     .     .     . 

Mottled,  as  in  aquo-capsu  litis.   .     . 

One-half  destroyed,  ossicles  and 
remnant  drawn  upwards  and 
backwards. 

Aperture  anteriorly;  malleus  unseen 

Collapsed:  white:  malleus  projecting 

Collapsed,  white,  pulpy,  .     .     .     . 

Opaque,  vascular,  with  deep-red 
spot  in  centre  of  anterior  part.     . 

Large  aperture  inferiorly.      .     .     . 


Uninflatable. 


Tymp.  cavity 

uninflatable. 

Uninflatable. 

Ditto. 

Inflat.;  memb, 
made  vascular 

Inflatable. 

Inflatable. 

Inflatable. 
Uninflatable 

Inflatable. 


Ditto 

A  uniform  pink 

Collapsed,  highly  vascular. 


Itching. 


Originally. 


None. 
None. 


Ditto. 

Giddiness. 


Originally. 

None. 

None. 
Occasional. 

None. 

None. 


Ditto. 

Throbbing 

Severe. 

Stinging. 


Tinnitus. 
Whistling. 

None. 
Tinnitus. 


None. 


None. 


Ditto. 

Hammerint 

Ringing. 


On  first  ac- 
cession. 


Uninflatable. 
M.  granular 

Inflatable. 

Inflatable. 
Ditto. 
Membrane 

thickened, 

red. 
Ditto. 
Uninflatable, 

Inflatable. 

Inflatable. 

Memb.villous. 


E.  tube  closed. 

Inflatable. 
Uninflatable. 


Most  severe 

None. 
Ditto. 

None. 

Ditto. 

None. 
Violent. 

None. 

Ditto. 

Slight. 
Rheumatic 
Originally. 

None. 
Occasional. 

Ditto. 

None. 


Ditto. 
Original. 

Ditto. 
Original. 

None. 

Ditto. 
Severe. 
None. 


Buzzing. 

Ringing. 

Drumming 

Ticking. 
Ditto. 

Tidal. 

Ditto. 

Like  bells. 

Throbbing, 

Steaming. 

Ditto. 

None. 

Tidal 

Hammerini 

Singing. 

Buzzing. 

Ditto. 

None. 


Ditto. 
Musical. 

Ditto. 
Rustling. 

Boiling. 

Ditto. 

Buzzing. 

Ditto. 


Normal. 
Normal. 


Scarlatina. 


Normal. 
Normal. 

Normal. 
Normal. 


Erysipelas. 


Normal. 


Normal. 


Normal. 
Normal. 

Normal. 

Normal. 

Normal. 

Normal. 

Normal. 


Normal. 


Normal. 
Normal. 
Normal. 


Red. 

Normal. 
Normal. 


Red. 

Normal. 


Normal. 


Normal. 
Normal. 


Normal. 


Influenza. 
Scrofula. 


Cold. 
Severe  sy- 
ringing 
Cold. 

Cold. 


Cold. 
Scarlatina. 


Cold. 
Cold. 

Cold. 


Cold. 


Small-pox. 


Cold. 
Fever. 


Cold. 


136 


EEGISTRY    OF    EAR    CASES. 


No. 

of 

Case. 


Sex.     — 


Ear 
affec- 
ted. 


Duration 

of 
Disease. 


Hearing 
Distance. 


State  of  Auricle. 


State  of  External  Meatus  and  Canal. 


156 
157 


158 
159 


160 


161 
162 

163 


164 
165 

166 

167 

168 
169 

170 

171 

172 

173 

174 

175 
176 


177 
178 


F.    20< 


F.    35- 


20' 


M.  38 


F. 


M. 


M. 


M. 


M. 
F. 


F 

M. 


16 


13- 


40 


25 


R. 


4  years. 
11  years. 

2  years. 

Ditto. 

1  year. 

10  years. 


9  years. 

2  years. 

4  months. 

4  days. 


1  year. 


9  months. 
14  years. 


4  days. 


15  years. 


10  years. 


7  years. 


6  months. 


4  years. 

6  months. 
4  months. 


2  years. 


1  year. 


5  years. 
3  weeks. 


6  inches. 
None. 

Touching 
2  inches. 

1  inch. 

None. 


Ditto. 

1  inch. 

None. 

None. 

3  inches. 


4  inches. 


2  inches. 
None. 


Touching. 


3  inches. 
None. 


1  inch. 
1  foot. 
None. 
1  inch. 
Touchins 


None. 
2  inches. 


4  inches. 
2  inches. 


2  feet. 
None. 


Touching. 

1  inch. 

2  inches. 

1  inch. 

2  inches. 
Touching. 


Normal. 
Normal. 

Normal. 

Ditto. 

Red,  scaly. 

Normal. 


Ditto. 

Normal. 

Normal. 

Normal. 

Ditto. 

Normal. 


Ditto. 
Lumpy  from  a 
contusion. 
Normal. 

Ditto. 
Swollen,  red, 
and  painful. 

Normal. 

Ditto. 
Normal. 

Ditto. 

Normal. 


Ditto. 
Helix  wanting; 
purple. 
Normal. 

Normal. 

Ditto. 
Erysipelatous ; 
mastoid  region 
enlarged. 
Normal. 
Ditto. 
Irregular;  no 
lobe. 
Normal. 

Normal. 
Normal. 


Contracted ;  thickened  ;  discharge.  . 
Filled  completely  with  large  poly- 
pus, which  projects  externally. 

Brown-red,  dry 

Dry,  scaly,  pink 

Contracted,  whitish  discharge.     .     . 
Normal ;  never  had  discharge.     .     . 


Ditto. 


Normal. 
Dry.    . 


Filled  with  pus  and  air  bubbles. 
Contains    thin    muco-purulent    dis- 
charge. 
No  cerumen  ;  pinkish 


Normal. 
Normal, 


Very  red;  had  discharge  originally. 


Dry  and  polished 

Swollen ;   coated  with   lymph   and 

muco-purulent  discharge ;  filled  by 

a  grain  of  Indian  corn. 
Dry;  no  cerumen 


Osseous  encroachment  posteriorly ; 
discharge  originally. 

Dry;  no  cerumen;  previous  dis- 
charge. 

Filled  with  discharge  and  air  glo- 
bules. 

Dry,  scaly 


Filled  with  discharge 

Enlarged;  smeared  with  discharge. 

Dry,  with  membrane  corrugated.     . 


Dry;  no  cerumen. 


Filled  by  several  smair  abscesses.   . 

Contracted;  filled  with  crusts;  gra- 
nular inferiorly;  a  thin  scale  of 
bone  projecting. 

Filled  by  discharge  and  air  globules 

Filled  with  scales  and  cerumen. 

Filled  with  cerumen 


Normal. 


Sanious  discharge  from.      .     .     . 
Filled  with  scales  and  cerumen. 


EEGISTRY    OF    EAR    CASES. 


13T 


State  of  Membrana  Tympani. 


Middle  Ear 
and  Eusta- 
chian Tube. 


Pain. 


Noise. 


State  of 
Tliroat. 


Disease  attri- 
buted to. 


Unseen. 
Unseen. 


Thickened,  opaque,  polished.    .     . 

Opaque,  mottled,  polished.    .     .     . 

Unseen 

Dense  ■white;  thickened;  clear  de- 
pressed spots  behind  malleus,  and 
opposite  to  Eustachian  tube. 

Flat;  skimmed-milk  color,  with 
clear  dimple  inferiorly. 

An  uniform  pink 

Flat ;  slightly  opalescent 

Mottled ;  a  pulsating  rent  anteriorly. 

Thickened,  opaque,  vascular  above. 


Uninflatable. 
Inflatable. 


Inflatable  in 
pockets. 

Uninflatable. 


Inflatable. 
Uninflatable. 


None. 
None. 

None. 

Ditto. 

Soreness 

None. 


Ditto. 

Pain. 

None. 

Intense. 


None. 
Tidal. 


Normal. 


None. 

Ditto. 

None. 

Blowing 

and  singins 


Normal. 


Cold. 


Normal. 
Normal. 


Ditto. 


Singing. 
Confused. 
Reports. 


Normal. 

Normal. 

Red. 


Much  collapsed ;  opaque;  malleus 
projecting;  irregular;  white  spots; 
clear  patch  anteriorly. 

Collapsed;  white  below,  red  above. 

Thickened,  opaque,  like  old  parch- 
ment; vascular  above. 

Collapsed  ;  a  dense  purple  red,  but 
polished;  malleus  prominent. 

Thickened;  small  aperture  inferiorly 

On  removal  of  foreign  body,  mem- 
brana tympani  found  coated  with 
adhesive  lymph. 

Crescentic  opacity  inferiorly;  and 
clear,  thin  concavity  posteriorly. 

Collapsed,  opaque;  irregular,  clear 
depression  posteriorly. 

Collapsed,  thickened,  opaque;  gra- 
nular in  centre. 

Vascular ;  perforate  opposite  Eusta- 
chian opening. 

Much  thickened;  orange  red  infe- 
riorly; malleus  indiscernible; 
white  streak  crossing  lower  part. 

Thickened,  opaque,  vascular.     .     . 

Rose-colored,  rugged,  granular. 


Uninflatable 
malleus  red. 

Ditto. 

Uninflatable, 
Ditto. 

Inflatable. 
Ditto. 


Occasional. 


Originally. 


Buzzins 


Normal. 


Ditto. 
Buzzins 


Tinnitus. 


Normal. 


Intense. 

None. 
Ditto. 
None. 


None. 
Buzzins 


Running 
water. 
Ditto. 

Tinnitus. 


Normal. 

Normal. 
Ditto. 


Inflatable. 


Skimmed-milk  color; 

cent  inferiorly. 
Rose-colored,  polished. 


white   cres- 


Uninflatable. 
Inflatable. 


None. 


Occasional. 

None. 

Ditto. 


Sawing. 


Tidal. 


Normal. 
Normal. 


Ditto. 
Normal. 


Ditto. 


Undiscernible. 
A  florid  red.   . 


Uninflatable. 


Red  and  white ;  perforate  posteriorly 
IrreguIar,corrugated,with  clear  spots 
Skinmied-milk  color;  spotted  with 

white  ;  red  over  malleus. 
Crescentic    opacity  below;    white 

band  across. 

Perforate  posteriorly 

Rose-colored;  mottled  with  white. 


Originally. 

at  night. 

Originally. 

Originally. 


None. 


Normal. 


Tinnitus. 


None. 


Normal. 
Normal. 


Memb.  red 


Scrofula  and 
spine  dis- 
ease. 


Fever. 
Cold. 


Injury. 


Typhus. 
Foreign 
body. 

Diving. 


Scarlatina. 


Stupidity. 


Cold. 


A  blow. 


Inflatable;  M, 

T.  reddened. 

Ditto. 


None. 
Ditto. 


Inflatable. 


Tidal. 
Ditto. 
Tidal. 


Normal. 


Cold. 


Tonsils  en- 
larged. 


Cold. 


138 


REGISTRY    OF    EAR     CASES. 


No. 

of 

Case. 


Sex. 


Age. 
Yrs. 


Ear 

aftec 
ted. 


Duration 

of 
Disease. 


Hearing 
Distance. 


State  of  Auricle. 


State  of  External  Meatus  and  Canal. 

Collapsed  to  mere  slit;  covered  with 
discharge;  epithelium  abraded. 

Pinkish,  dry 

Dry,  scaly 

Scaly;  cuticle  thickened 

Normal. 

Filled  by  hard,  dark  cerumen.  .  . 
Filled  by  thick,  yellow  discharge.  . 
Widened;  filled  with  crusts.  .     .     . 

Filled  by  discharge  and  air  bubbles. 

Filled  with  discharge 

Normal 

Sides  collapsed,  thickened.      .     .     . 

Ditto 

Enlarged;  pink;  its  bottom  filled 
with  discharge  and  air  globules.    . 

Ditto 

Normal 

Normal 

Dry;  no  cerumen 

Normal 

Normal 

Red ;  dry,  and  scaly 

Ditto 

A  mere  slit ;  edges  in  contact.  .  . 
Normal 

Dry,  scaly;  introduction  of  speculum 
induces  spasmodic  coughing. 

Ditto 

Wrinkled ;  some  cerumen.  .  .  . 
Filled  by  discharge;  small  polypus 

attached  immediately  in  front  of 

membrana  tympani. 
Normal ■ 

Filled  with  cerumen 

Normal 

Excoriated  with  discharge  ;  air  bub- 
bles and  polypus. 

Filled  with  fcEtid  discharge  and  poly- 
pus. 

Excoriated  and  filled  with  very  foetid 
discharge;  polypus  attached  poste- 
riorly. 

Dry  and  scaly 

Ditto . 


Filled   with    cerumen   and  foreign 
substances. 


179 


180 
181 


182 
183 


185 
186 

187 

188 
189 

190 

191 

192 
193 

194 
195 

196 

197 
198 

199 

200 


M. 

F. 

M. 

M. 
F. 

F. 

M. 
F. 

M. 

M. 
M. 

M. 

M. 

F. 

M. 


M. 


M. 


M. 


M. 


F. 


M. 


20 
26 

40 
13 

17' 

24- 

40- 

22- 

50 
25- 

10  ■ 

30 

50 
40 

60 
31  ; 

40< 

14; 
17 

20 

19 


2  months. 


L. 


7  months. 


1  month. 

2  months. 
10  years. 
9  years. 

Ditto. 

5  years. 

Ditto. 

3  months. 


2  months. 


Ditto. 
2  years. 
1  year. 


6  years. 

Ditto. 

4  years. 

Ditto. 
12  years. 
10  years. 

25  years. 


4  years. 

6  years. 
4  years. 


10  years. 

Ditto. 

12  years. 
Ditto. 

10  years. 

Ditto. 


5  years. 
6  months. 


3  years. 


Touching. 

1  inch 
None. 

Touching. 

Touching. 

Variable. 

None. 
Touching. 

1  inch. 
None. 
1  inch. 
4  inches. 
1  foot. 
None. 


Ditto. 
None. 
None. 
Ditto. 

Touching. 

8  inches. 
None. 

Ditto. 

9  inches. 
Touching. 

Pressing. 


Touching 


None. 
Touchins 


None. 


Ditto. 


4  inches. 
1  inch. 


9  inches. 
Touching 


Touching 
1  foot. 


4  inches. 


Normal. 

Ditto. 
Normal. 

Ditto. 
Normal. 

Normal. 
Normal. 
Irregular. 

Normal. 

Normal. 

Ditto. 

Normal. 
No  helix. 
Normal. 


Ditto. 

Normal. 
Normal. 
Irregular. 

Normal ;  mastoid 

gland  enlarged. 

Normal. 

Normal. 

Ditto. 

Flattened. 

Normal. 

Normal. 


Duto. 

Normal. 
Ditto. 


Normal. 

Ditto. 

Normal. 
Ditto. 

Helix  deficient. 

Normal. 


No  lobe. 
Ditto. 


Normal. 


REGISTRY    OF     EAR    CASES. 


139 


State  of  Membrana  Tympani. 


Middle  Ear 
and  Eusta- 
chian Tube. 


Pain. 


State  of 
Throat. 


Disease  at- 
tributed to. 


Sloughy;  an  ash-gray  color.   .     .     . 

Collapsed,  thickened,  and  opaque. 

Slightly  opaque ;  whitish  below.    . 

Opaque  below;  pink  above.       .     . 

Florid  red ;  malleus  unseen ;  Facial 
paralysis  on  left  side. 

White;  ext.  layer  removed  with  wax. 

Vascular;  perforate  inferiorly.    .     . 

Thickened;  pulsating  aperture  be- 
low. 

Nearly  removed 

Deficient  posteriorly 

Pearly,  streaked  with  red.     .     .     . 

Collapsed,  thickened;  malleus  red. 

Opaque  and  thickened,      .... 

Mottled  red  and  white  ;  small  aper- 
ture opposite  Eustachian  opening, 
which  emits  a  whistling  sound. 

Ditto 

Perfectly  normal 

Col  lapsed,  like  crumpled  parchment 

Collapsed;  opaque  crescent  infe- 
riorly. 

Irregularly  polished;  pink  zone  in- 
feriorly. 

Slightly  opaque,  but  polished.    .     . 

Collapsed ;  blight  pink  over  malleus 

Much  collapsed;  pink  above.    .     . 

Thickened,  opaque,  vascular.     .     . 

Opaque,  except  one  clear  spot  an- 
teriorly. 

Thickened,  opaque,  like  parchment; 
opacity  deepens  at  inferior  edge, 
and  over  malleus. 

Collapsed,  thickened;  a  triangular, 
clear  spot  below  malleus. 

Collapsed,  thickened,  opaque.    .     . 

Opalescent ;  small  aperture  in  centre. 


Collapsed,  polished;  malleus  promi- 
nent, clear  in  middle;  crescent  of 
opacity  in  front. 

Unii'briTiIy  thickened;  white  cres- 
cent inferiorly. 

Opalescent 

Perforate  anteriorly 


Inflatable. 


Severe. 


Inflatable. 
Uninflatable. 


Inflatable. 
Villous. 

Very  red. 
Memb.  white. 

Inflatable. 

Uninflatable. 

Ditto. 

Inflatable. 


Ditto. 

Inflatable. 

Uninflatable. 

Ditto. 

Uninflatable. 

Ditto. 
Uninflatable. 

Ditto. 

Uninflatable. 

Inflatable. 

Inflatable;mal 
leus  becomes 
vascular. 
Uninflatable. 

Uninflatable. 
Inflatable. 


Inflatable. 


Ditto. 


Uninflatable. 
Inflatable. 


None. 


Like  wind. 

Ditto. 
Tidal. 


Normal. 


Cold. 


Ditto. 
Cold. 


Severe  at 
night. 
None. 
None. 
None. 

None. 
Originally. 

None. 
Originally. 

None. 

None. 


In  head. 

Intense. 

Ditto. 

Pain  for  two 
months. 
None. 
None. 

Ditto. 

None. 
None. 

None. 


Ditto. 

None. 
None. 


None. 


Ditto. 

Occasional. 
None. 


Tinnitus. 

Like  wind. 

None. 
Like  mill. 


None. 

None. 

None. 
Tinnitus. 

Ditto. 
Whizzing. 


Normal. 

Normal. 

Normal. 

Memb.  red 


Cold  and 
exposure. 


Normal 


Normal. 
Normal. 


Cold. 


Cold. 


Boiling. 

Buzzing. 

Confused. 

Ditto. 


Normal. 
Ulcerated. 


Intern  pere. 
Syphilis. 


None. 

None. 
Fizzing, 

Ditto. 

Rasping 

Tidal. 

Tidal. 


Ditto. 

Hushing 
Ditto. 


Tidal,  roar- 
ing. 

Ditto. 

Ringing. 


Normal. 


Measles. 


Tonsils  en- 
larged. 


Cold. 


Normal. 
Normal. 

Normal. 


Parturition 


Normal. 


Cold. 


Normal. 

Ditto. 
Normal. 


Wearing  a 
wet  cap. 


Fall  on  head 


Unseen. 
Ditto. 


Measles. 


Normal. 


Thickened  and  much  collapsed.  . 
Bands  of  opacity,  with  clear  space 
between,  reflecting  light  over  large 
surface,  but  decreased,  and  mem- 
brane bulged  outward  on  inflation. 
Thickened,  collapsed,  vascular. 


Uninflatable. 
M.  inflatable 
in  clear  spot. 

Uninflatable. 


None. 
Ditto. 


Originally. 


Crackling. 
Ditto. 


Buzzing. 


Normal. 
Ditto. 


Normal. 


Typhus 
Ditto. 


Fractured 
cranium. 


140  ANALYSIS    OF    REGISTRY. 

It  must  be  remembered  that  all  these  cases  were  taken  down  at 
length  by  a  short-hand  writer,  and  that  the  condition  of  the  meatus 
and  the  state  of  the  membrana  tympani,  as  seen  through  the  specu- 
lum, were  the  two  principal  objects  attended  to.  In  cases  of  manifest 
disease  of  the  external  ear,  or  upon  the  surface  of  the  membrana 
tjmpani, — sufficient  to  account  for  the  symptoms  presented, — an  ex- 
amination of  the  state  of  the  tympanal  cavity  was  seldom  made. 
The  blanks  in  some  columns  show  that  the  symptoms  or  appearances 
to  which  that  particular  space  is  devoted  were  not,  in  those  instances, 
present,  or  that  the  statement  of  the  patient  on  that  point  were 
unsatisfactory.  I  have  lately  had  a  form  of  registry  printed  for  the 
Hospital,  containing,  in  addition  to  the  foregoing,  columns  for  the 
date,  definition  of  affection,  treatment,  and  observations,  &c., — the 
tabulated  results  of  which  will,  I  trust,  in  time,  still  further  assist  the 
examination  and  diagnosis  of  aural  aflFections. 

Dr.  Kramer,  in  his  review  of  my  writings  in  the  last  edition  of  his 
large  work  on  the  Ear,  says  that  I  have  been  illogical  in  my  deduc- 
tions ;  "this  may,  possibly,  be  the  case,  but  I  believe  that  it  will  be 
acknowledged  that,  in  medical  science,  one  well-established  fact,  and 
truthful  observation,  is  worth  a  hundred  syllogistic  ally  arranged 
arguments. 

Duration  of  Disease. — The  duration  of  the  disease,  as  well  as  the 
hearing  distance,  is  difficult  to  tabulate,  owing  to  the  variation  in 
those  cases  where  both  ears  were  affected.  In  some  instances  the 
patients  gave  such  an  unsatisfactory  account  of  their  disease,  that  the 
most  which  could  be  gleaned  was,  that  they  had  been  "  deaf  for 
years."  As  a  general  result,  the  following  particulars  flow  from  this 
portion  of  the  examination : — In  27  persons,  the  disease  was  within 
one  month's  duration ;  in  40,  from  one  to  six  months ;  in  17,  from  six 
to  twelve ;  45  persons  were  affected  from  one  to  five  years ;  29  from 
five  to  ten ;  and  34  over  that  period.  In  the  analysis  of  this  column 
the  duration  is  given  from  the  ear  longest  affected. 

The  hearing  distance  observed  may  be  thus  classified : — 70  could 
not  hear  the  watch  under  any  circumstances ;  4  heard  on  its  being 
pressed  against  the  auricle ;  61,  on  merely  touching  that  part ;  125, 
within  six  inches ;  22,  from  that  distance  to  three  feet  and  upwards  ; 
and  in  18  the  hearing  distance  was  either  normal  or  unrecorded. 

The  auricle  was  healthy  in  264  instances ;  presented  congenital 
peculiarities  in  10 ;  and  was  diseased  in  26. 

The  state  of  the  meatus  and  external  auditory  canal  may  be  thus 


STATE     OF    THE     MEMBRANA    TYMPANI.  141 

defined : — Normal  in  68  ;  dry  and  devoid  of  cerumen,  with  the  mem- 
brane whiter  than  natural,  and  slightly  wrinkled,  or  presenting  to- 
wards its  outward  margin  a  few  dry  scales, — characteristics  of  disease 
in  the  neighboring  structures  and  general  accompaniments  of  deaf- 
ness,— 78.  It  was  coated  with  discharge,  the  lining  thickened,  and 
frequently  of  a  pink  color  or  vascular,  or  the  passage  filled  with 
crusts  of  inspissated  mucus  from  previous  discharge,  in  83  instances ; 
and  of  these  cases,  18  had  polypi  growing  from  some  portion  of  the 
canal.  In  25  cases  the  passage  was  filled  with  cerumen  of  different 
qualities  and  degrees  of  consistence ;  these,  however,  form  no  propor- 
tion of  the  cases  of  deafness  arising  from  simple  impaction  with  ceru- 
men which  occurred  during  the  period  when  the  foregoing  200  cases 
were  recorded,  but  are  inserted  in  the  Registry  on  account  of  other 
abnormal  conditions  which  presented,  both  as  regards  the  patholo- 
gical appearance  of  the  membrana  tympani,  or  the  middle  ear,  on  the 
removal  of  the  offending  body.  In  26  cases  the  canal  was  inflamed ; 
in  9  its  walls  were  so  much  thickened  or  approximated,  as  to  give  the 
external  auditory  aperture  the  appearance  of  a  mere  slit;  bony 
growths  presented  in  4  instances ;  and  a  few  cases  occurred  of  condy- 
lomata and  other  protuberances  filling  up  the  meatus  ;  4  cases  of  con- 
genital peculiarities,  as  regards  the  length,  width,  and  tortuosity  of 
this  canal,  also  presented,  as  may  be  learned  by  an  examination  of 
the  cases  in  detail.  In  order  to  economize  space,  much  contraction 
was  obliged  to  be  used  in  the  terms  employed  for  recording  the  state 
both  of  the  external  meatus  and  the  membrana  tympani. 

The  state  of  the  memhrana  tympani  is  the  most  valuable  result 
aJfforded  by  the  examination  of  these  cases.  In  10  instances  only  was 
it  found  natural,  so  that  such  may  fairly  be  stated  as  the  proportion 
of  cases  of  "  nervous  deafness."  In  176  it  was  thickened  and  opaque, 
in  whole  or  in  part,  from  disease  of  its  external  layer,  owing  to  in- 
flamations  of  various  kinds — with  and  without  otorrhoea,  pressure,  or 
ulceration — from  deposits  of  lymph  between  its  laminse,  or  from 
thickening  or  vascularity  of  its  mucous  lining.  These  opacities  varied 
as  much  in  shade  as  the  same  forms  of  disease  present  in  the  cornea 
— from  a  slight  nebula  to  that  of  a  dense  white  leucoma ;  and  the 
analogy  between  the  diseases  of  these  two  structures,  the  cornea  and 
membrana  tympani,  can  only  be  appreciated  by  those  conversant  with 
both.  Sometimes  it  presented  a  slight  opalescence,  or  skimmed-milk 
hue ;  at  others,  a  general  dense  opacity,  and  in  these  cases  the  mem- 
brane was  most  frequently  collapsed.     In  some  cases  the  opacity 


142  ANALYSIS    OF    EEGISTRT. 

presented  a  mottled  appearance,  like  that  seen  on  the  back  of  the 
cornea  in  aquo-capsulitis  ;  in  others  it  appeared  like  mother-of-pearl. 
The  most  frequent  site  of  isolated  dense  opacity  was  the  inferior  at- 
tachment of  the  membrane,  where  it  presented  a  crescentic  white 
band,  about  a  line  in  breadth,  and  somewhat  resembling  the  arcus 
senilis.  In  a  feAV  instances  a  dense  white  line  stretched  between 
the  extremity  of  the  malleus  and  some  point  of  the  circumference  of 
the  membrane.  Around  the  attachment  of  the  malleus  it  was  fre- 
quently thickened  and  opaque.  In  many  cases  there  was  a  yellowish 
tint  imparted  to  the  membrane,  which  gave  it  somewhat  the  appear- 
ance of  old  or  crumpled  parchment. 

In  13  cases  there  were  connected  with  these  various  states  of  opacity 
thin  clear  spots  of  membrane,  about  the  size  of  mustard-seeds,  which, 
when  air  was  pressed  into  the  cavity,  generally  bulged  outwards  into 
small  pouches ;  and  this  phenomenon  occurred  even  in  instances  in 
which  the  membrane  as  a  whole  did  not  appear  to  be  affected  by  the 
volume  of  air.  It  is  not  improbable  that  thes6  were  the  sites  of 
ulcers  in  which  the  external  layer,  or  the  internal  mucous  one,  had 
been  removed,  and  the  middle  fibrous  structure  remaining  unaffected 
was  thus  pressed  outwards  into  small  hernise.  Occasionally  the  whole 
surface  of  the  membrane  was  irregular. 

The  amount  of  polish  was  various :  in  many  cases  the  surface  of 
the  membrane  resembled  muffed  glass ;  in  others,  although  there 
was  considerable  opacity,  the  normal  shining  character  was  preserved, 
and  light  reflected  in  the  usual  manner.  It  is  possible  that  in  these 
latter  cases  the  opacity  may  have  been  seated  in  the  mucous  layer 
lining  its  inner  surface. 

There  was  facial  paralysis  in  4  instances. 

In  4  cases  there  was  a  deposit  of  hard,  gritty  matter,  between  the 
laminae  of  the  membrane,  of  a  yellowish  color,  with  a  sharp,  defined 
edge,  like  the  atheromatous  substance  formed  between  the  coats  of 
arteries. 

It  is  not,  in  the  present  condition  of  our  knowledge,  always  possi- 
ble to  state  what  was  the  precise  form  of  inflammation  or  other 
disease  which  produced  the  effects  particularized  in  the  foregoing 
Registry,  which  merely  records  the  appearance  at  the  moment,  and 
the  pathological  results  of  previous  disease. 

In  121  cases  the  membrane  was  more  or  less  vascular ;  sometimes 
it  presented  a  uniform  pinkish  hue,  deepening  in  color  from  that  of 
a  monthly  rose-leaf  to  that  of  a  bright  blood-red  or  scarlet,  as  when 


STATE    OF    THE    MEM  BR  ANA    TYMPANI.  143 

aiFected  with  recent  inflammation.  Occasionally  the  redness  •was 
circumscribed,  presenting  a  zone  around  the  inferior  attachment  of 
the  membrane,  not  unlike  that  seen  in  cases  of  corneitis ;  in  others, 
showing  several  small  dots,  or  brightening  the  site  of  the  attachment 
of  the  malleus.  In  noting  the  cases,  a  distinction  was  made  between 
tints  of  color  and  vascularity ;  in  the  latter  the  red  vessels  were  dis- 
tinct and  plainly  discernible.  Where  the  naturally  thickened  mem- 
brane shelves  off  gradually  into  the  roof  of  the  meatus  is  a  very 
common  locality  for  redness  and  vascularity,  even  in  otherwise  healthy 
membranes.  Where  distinct  vessels  could  be  traced,  they  were  gene- 
rally observable  in  that  position,  or  coursing  from  above  downwards 
along  the  manubrimn,  or  spreading  from  the  point  of  that  bone  to 
the  posterior  or  inferior  attachment  of  the  membrane.  -  In  some 
instances  the  whole  surface  was  not  only  of  a  deep  red,  but  also 
granular,  like  that  of  a  ripe  raspberry,  or  the  appearance  so  fre- 
quently presented  on  the  inside  of  the  upper  eyelid; — such  were 
cases  of  long-continued  otorrhoea.  Although  this  carneous  condition 
was  often  seen,  and  although  so  many  cases  of  otorrhoea  and  polypus 
occurred,  I  have  never  observed  a  polypus  growing  from  the  external 
siu-face  of  the  membrana  tympani,  either  in  these  200  cases,  or  in  the 
many  hundred  ears  that  I  have  examined.  The  general  red  color, 
as  well  as  the  distinct  vascularity,  was  always  increased  by  any  attempt 
made  by  the  patient,  whether  successful  or  not,  to  force  air  into  the 
tympanal  cavity.  That  blood  is  decidedly  pressed  into  the  structures 
of  the  ear  by  a  forced  expiration,  or  inflation  after  the  manner  de- 
scribed at  page  74  I  had  very  recently  an  opportunity  of  determining. 
I  removed  a  polypus  attached  by  a  fine  peduncle  to  the  anterior  wall 
of  the  meatus,  near  the  attachment  of  the  membrana  tympani; 
nothing  remained  of  it  but  the  bright-red  spot  from  which  the  morbid 
structure  grew.  After  the  hemorrhage  ceased,  and  when  the  parts 
were  brought  into  the  field  of  the  speculum,  I  desired  the  patient  to 
inflate  the  drum,  when  I  remarked  that  each  time  he  did  so,  the  blood 
pumped  out  of  the  spot  from  which  the  polypus  had  been  cut. 

In  53  cases  the  membrana  tympani  was  more  or  less  collapsed,  a 
condition  already  referred  to  at  page  28,  and  the  cause  of  which 
would,  from  the  dissections  of  both  Mr.  Swan  and  Mr.  Toynbee, 
appear  to  be  adhesions  passing  through  the  cavitas  tympani,  either 
between  the  mucous  surface  of  the  membrane  itself,  or  the  ossicula 
connecting  it  with  the  inner  wall  of  that  cavity,  and  thereby  limiting 
their  and  its  motions.     In  the  majority  of  these  instances,  neither  by 


144  ANALYSIS    OF    EEGISTRY. 

natural  nor  artificial  means  could  the  vibrating  portion  of  the  mem- 
brane be  pressed  outwards,  although  in  some  of  these  cases  there  was 
positive  proof,  by  catheterism  and  the  air-pump,  that  the  Eustachian 
tubes  were  free.  As  might  naturally  be  expected  where  the  mem- 
brane was  drawn  so  much  inwards,  either  by  the  mechanical  causes 
alluded  to,  or  from  pressure  of  the  external  atmosphere  where  the 
Eustachian  tubes  were  not  free,  the  malleus  projected  outwards  con- 
siderably beyond  the  line  of  the  membrane,  which  dipped  from  it, 
like  a  festoon,  on  either  side.  The  great  bulk  of  these  cases  of  col- 
lapsed membrane  also  showed  evidences  of  thickening  and  opacity. 
The  membrane  was  perforated  in  48  cases,  the  size  and  position  of 
the  aperture  presenting  great  variety.  In  most,  but  not  all  of  these, 
the  air  passed  through  with  a  whistling,  squeeling,  bubbling,  or  gurg- 
ling sound, — each  peculiar  tone  being,  no  doubt,  produced  by  the  size, 
position,  and  valvular  character  of  the  aperture,  as  well  as  the  fluids 
through  which  the  stream  of  air  passed,  and  possibly  also  by  the  con- 
dition of  the  margin  of  the  hole,  which  was  sometimes  thickened,  and 
frequently  inverted.  In  25,  the  perforation  existed  inferiorly  or  an- 
teriorly, opposite  the  opening  of  the  Eustachian  tube ;  in  10,  poste- 
riorly ;  and  in  13  the  great  bulk  of  the  membrane  was  removed ;  and 
the  remnant,  with  the  ossicles,  was  drawn  upwards  and  backwards, 
while  the  cavity  of  the  tympanum,  and  the  promontory  in  particular, 
was  distinctly  visible,  with  its  lining  membrane  red  and  villous.  In 
22  instances  the  membrana  tympani  was,  from  obstructions  in  the 
canal,  unseen. 

The  state  of  the  middle  ear  and  Eustachian  tube  is  not  so  satis- 
factorily recorded  as  that  of  either  of  the  foregoing  subjects,  as  it  is 
not  possible  to  diagnose  with  accuracy  the  pathological  condition  of 
this  unseen  cavity.  Where  manifest  disease  showed  in  the  membrana 
tympani,  or  where  that  structure  was  open — with  muco-purulent  mat- 
ter pumping  through  it — it  may  be  fairly  supposed  that  the  fine 
mucous  lining  of  the  cavitas  tympani  could  not  have  been  in  a  per- 
fectly healthy  condition.  Where  the  aperture  in  the  membrana- 
tympani  was  sufficiently  large  to  admit  of  inspection  of  the  parts 
beyond,  their  condition  is  generally  stated  in  the  tenth  column  of  the 
Registry.  The  cavity  was  exposed  in  28  ears ;  in  89  there  is  no 
record  of  its  state ;  in  129  it  was  inflatable,  and  in  73  uninflatable, — 
the  mode  of  examination  being,  in  most  instances,  that  described  at 
page  74.     In  many  instances,  particularly  those  in  the  latter  portion 


CLASSIFICATION    OF    AURAL    AFFECTIONS.  145 

of  the  Registry,  an  exploration  was  made  ])j  means  of  the  Eustachian 
catheter  and  air-press. 

Pain. — The  statement  given  on  this  point  must,  particularly  in 
cases  of  long  standing,  be  received  with  caution.  In  115  instances 
the  patients  had  experienced  pain,  either  in  one  or  both  ears,  at  some 
particular  period  of  the  disease.  In  124  cases  they  stated  that  they 
had  never  had  pain ;  and  in  61,  the  notes  from  which  this  Registry 
has  been  compiled  make  no  statement  upon  the  subject. 

Noise. — In  182  cases  there  was  tinnitus ;  in  58,  none  ;  and  in  60 
there  is  no  record.  What  I  have  already  written  upon  the  subject, 
at  page  90,  may  serve  as  an  explanation  for  the  summary  of  this 
symptom. 

The  state  of  throat  was  normal  in  181  cases  out  of  the  200,  a  fact 
which  goes  far  to  disprove  all  that  has  been  written  upon  what  has 
been  termed  "throat  deafness ;"  but  then  it  is  only  fair  to  state,  that 
enlarged  tonsils  are  rare  among  the  lower  orders. 

The  disease  ivas  attributed  to  cold,  or  variations  of  temperature, 
by  sitting  opposite  a  broken  window,  or  being  exposed  to  a  draft  of 
air  in  a  railway  carriage,  &c.,  in  63  cases ;  to  scarlatina,  in  14 ;  fever, 
8  ;  measles,  3  ;  influenza,  3  ;  scrofula,  4 ;  syphilis,  2 ;  and  bathing  in 
the  sea,  5 ;  injury  or  accident,  11 ;  occurred  after  parturition,  3 ;  fol- 
lowed erysipelas,  2 ;  small-pox,  1 ;  intemperance,  1 ;  and  in  the  re- 
mainder, the  patients  were  unable  satisfactorily  to  account  for  the 
accession  of  disease.  It  must,  however,  be  borne  in  mind  that  the 
persons  from  whom  these  accounts  were  received  belong  to  a  class 
that  pay  but  little  attention  to  the  early  symptoms  of  deafness,  and 
that  in  very  many  the  disease  approached  gradually  and  without 
warning.  In  children  and  young  persons  the  first  symptoms  of  deaf- 
ness are,  unless  accompanied  by  pain  or  discharge,  generally  un- 
attended to,  or  are  attributed  by  the  friends  to  inattention  or  stu- 
pidity. 

From  the  records  of  the  foregoing  200  cases,  taken  indiscrimi- 
nately as  they  presented  at  a  public  institution,  as  well  as  Mr.  Toyn- 
bee's  dissections  already  detailed,  it  is  incontrovertibly  manifest  that 
inflammatory  afiections  of  some  form  or  other  have  been  the  chief 
cause  of  aural  diseases.  This  conclusion  must,  I  think,  be  conceded ; 
and  it  is  of  vast  importance  that  the  profession  should  be  convinced 
on  that  point,  as,  on  the  one  hand,  it  shows  not  only  the  inapplica- 
bility of  the  various  nostrums  still  in  use  for  "  deafness,"  while,,  on 
the  other,  it  holds  out  a  fair  hope  of  alleviating  diseases  of  the  ear,  if 

10 


146  CLASSIFICATION    OF    AURAL    AFFECTIONS. 

taken  in  time,  by  the  ordinary  means  in  use  for  arresting  inflammation 
of  the  structures  engaged. 

That  a  large  proportion  of  diseases  of  the  ear  depend  upon  consti- 
tutional taint,  and  are  of  a  strumous  character,  is  well  known  to  most 
medical  practitioners.  In  some  of  Mr.  Toynbee's  dissections  the 
diseases  of  which  the  patient  died  have  been  recorded.  The  deaths 
of  52  were  attributed  to  diseases  of  the  lungs,  of  which  39  were  from 
consumption.^  Epidemic  diseases  carried  off  24,  of  which  16  were  by 
fever.  In  18  the  deaths  were  caused  by  diseases  of  the  brain  or 
nervous  system,  and  15  died  from  diseases  of  the  digestive  organs. 

Those  only  who  have  been  engaged  in  accm-ately  recording  cases, 
and  compiling  statistics  therefrom,  can  well  understand  or  appreciate 
the  labor  necessary  to  efiect  the  objects  intended.  In  concluding  this 
portion  of  my  work  I  would  earnestly  entreat  those  gentlemen  con- 
nected with  public  institutions  where  diseases  of  the  ear  are  treated, 
to  introduce  some  form  of  registry  by  which  a  record  may  be  pre- 
served of  the  physical  signs  exhibited  in  cases  of-  deafness ;  and 
occasionally  to  make  known  the  results. 

Having  now,  in  accordance  with  the  plan  laid  down  for  the  ar- 
rangement of  this  work,  given  some  account  of  the  principal  writings 
and  discoveries  connected  with  aural  surgery ;  having  entered  fully 
into  the  best  method  of  examination,  in  order  that  an  accurate 
diagnosis  might  be  formed ;  and  having  also  discussed  the  subject  of 
the  statistics  of  ear  diseases,  it  only  remains,  before  I  enter  upon 
their  description  and  treatment  in  detail,  to  offer  some  remarks  upon 
the  best  nosological  arrangement  of  these  affections. 

To  the  difficulties  attending  all  synoptical  arrangements,  we  have 
here  to  encounter  additional  ones,  arising  from  the  obscurity  of  the 
parts  affected :  and,  whether  we  attempt  a  classification  according  to 
the  symptoms,  as  the  means  employed  by  Cullen  and  Mason  Good, — 
or  base  it  upon  the  normal  or  morbid  anatomy  of  the  tissues  affected, 
as  by  our  modern  nosologists,  the  same  difficulties  beset  us. 

The  earliest  chart  of  aural  diseases  worth  mentioning  is  that  ar- 
ranged by  Galen.  It  consists  of  five  affections,  viz. :  otalgia,  haruc- 
hoia,  kophotis,  paraJcousis,  and  -paraJcousmata ;  but  these,  it  is  per- 
fectly evident,  were  but  symptoms,  not  diseases;  and  to  these  he 
added,  pain  in  the  ear  from  cold,  inflammation,  and  "  ex  flatulento 
spiritu  aut  crassis  et  viscosis  humoribus  est  ex  serosis  et  saniosis 
humorihus." 

The  first  attempt  at  an  arranged  nomenclature  of  aural  diseases  in 


CLASSIFICATION     OF    AURAL    AFFECTIONS.  147 

Great  Britain  was  that  by  Buchanan  in  1825,  who,  in  his  "  Illustra- 
tions of  Acoustic  Sui'gery,"  endeavored  to  classify  those  affections 
according  to  the  parts  engaged ;  but  his  diseases  are  mere  symptoms. 
It  contains  three  orders,  twelve  genera,  and  thii'ty-three  varieties ; 
that,  however,  his  division  is  most  imperfect,  nay,  in  some  respects, 
absurd,  may  be  learned  by  an  examination  of  his  fourth  genus  alone, 
styled,  '■'■  Impedimentwn  Externum,''  or  obstruction  of  the  external 
meatus,  under  which  he  enumerates  four  species,  each  resulting  from 
causes  totally  different,  and  quite  unconnected  with  one  another,  viz. : 
"  Impedimentum  Extraneum,  from  extraneous  substances ;  Impedi- 
mentum  Induratum,  from  indm-ated  wax ;  Impedimentum  Poly- 
posum,  from  polypi;  and  Impedimentum  Excrescens,  from  excres- 
cences ! !" 

At  page  47,  I  alluded  to  Mr.  Harvey's  "  Synopsis  of  the  Diseases 
of  the  Human  Ear,"  published  some  years  ago,  and  offered  an  opinion 
as  to  its  value  and  peculiarities.  As  a  further  example,  we  find  in 
Class  II.  (queer e  III.),  Order  I.,  Laburinthos — a  variety  of  diseases  : 
— Inflammations,  ulcerations,  perforations,  excrescences,  concretions, 
hydatids,  effusions  of  blood,  formations  of  pus,  &c.,  &c.,  affecting  the 
labyrinth,  and  also  the  fluid  of  that  cavity,  but  expressed  in  high- 
sounding,  Greek-derived  terms,  for  which,  as  special  diseases,  there  is 
no  warrant  that  I  am  aware  of.  It  is  high  time  to  get  rid  of  such 
attempts,  which  merely  mystify  the  student,  and  serve  to  frighten  the 
patient.  If  we  want  complexity  of  nomenclatm^e  in  diseases  of  the 
ear  we  had  better  apply  to  the  Chinese  or  the  Hindus.^ 

The  anatomical  division  into  the  external,  middle,  and  internal  ear, 
presents  a  natural  basis  for  classification,  and  such  was  the  method 
adopted  by  Du  Verney.  Deleau's  Table  is  perhaps  the  most  artifi- 
cial, and  at  the  same  time  incomplete ;  he  gives  five  classes,  two  of 
which  are  devoted  to  affections  of  the  Eustachian  tube :  the  first  is 
divided  into  two  orders,  for  the  alterations  produced  in  its  naso-gut- 
tural  orifice  by  pharyngeal  disease,  one  by  chronic  inflammation,  the 
other  from  enlarged  tonsils, — an  idea  that  has  been  much  enlarged 
and  improved  upon  in  England,  although  I  have  not  yet  heard  of 
a  single  dissection  showing  that  an  indurated  tonsil  in  any  way  pressed 
upon  or  produced  an  alteration  in  the  trumpet-mouth  of  that  canal. 
The  second  class  contains  three  orders,  consisting  of  simple  obstruc- 
tion, chronic  inflammation,  and  strictm-e  of  the  upper  portion  of  the 

'  See  Commentary  on  the  Hindu  System  of  Medicine,  by  T.  A.  "Wise,  M.D.,  Calcutta, 
1845,  page  287. 


148  CLASSIFICATION    OP    AURAL    AFFECTIONS. 

tube,  not  produced  by  disease  in  the  pharynx,  but  all  arranged  to 
meet  the  author's  peculiar  views  with  respect  to  Eustachian  cathete- 
rism  and  aural  auscultation.  His  third  class  consists  of  inflammation 
without  secretion,  and  muculent  accumulation  in  the  cavity  of  the 
tympanum ;  the  fourth  includes  inflammation  and  perforation  of  the 
membrana  tympani ;  and  the  fifth  is  devoted  to  complications  attend- 
ing diseases  of  the  middle  ear,  the  first  and  second  orders  of  which 
are  simply  combinations  of  the  foregoing ;  and  the  third  order  in- 
cludes diseases  of  the  middle  ear  and  labyrinth. 

In  the  two  first  editions  of  his  work  on  Diseases  of  the  Ear,  Kra- 
mer adopted  the  original  division  of  Du  Verney,  but  mingled  the 
anatomical  and  pathological  basis  in  the  subdivision  of  the  diseases  of 
these  parts ;  as  for  instance,  erysipelatous  and  phlegmonous  inflam- 
mations, and  also  inflammations  of  the  glandular,  cellular,  and  peri- 
osteal structures.  In  the  last  edition  of  his  work  he  adheres  through- 
out to  the  anatomical  basis,  as,  for  instance,  inflammation  of  the  cuti- 
cle, the  cutis,  the  cellular  membrane,  mucous  tissue,  and  periosteum,  &c. 

Mr.  Wharton  Jones's  arrangement  is  entirely  an  anatomical  one, 
consisting  of  two  parts,  viz. :  the  diseases  of  the  accessory  organs  of 
the  apparatus  of  hearing, — and  the  diseases  of  the  fundamental  organ 
of  hearing, — the  ear-bulb,  or  labyrinth, — with  the  minute  subdivisions 
of  both  these  portions. 

Mr.  Williams  does  not  attempt  any  classification  whatever ;  and 
Mr.  Pilcher's  work  is  likewise  defective  in  this  respect,  his  arrange- 
ment being  a  simple  enumeration  of  aural  afi"ections,  divided  into — 
the  abnormal  conditions  or  malformations  ;  otitis,  or  acute  inflamma- 
tion ;  chronic  diseases  of  the  ear  ;  and  nervous  diseases  of  the  ear. 

Lincke  is  by  far  the  best  modern  classifier :  he  makes  three  divi- 
sions ;  but  he  does  not  classify  the  diseases  of  the  sentient  portion  of 
the  auditory  apparatus,  or  those  producing  nervous  deafness.  We 
hope  to  see  a  third  volume  from  this  author  on  these  obscure  forms  of 
disease.     In  the  first  division  we  find — 

INFLAMMATIONS   OF   THE    ORGANS    OF   HEARING. 

SEC.  I. SIMPLE.  SEC.  II. — COMPLICATED    AND    SPECIFIC. 

Outer  Ear. — Attritus  AuriciilEe.  Otitis,  Erysipelatosa. 
Erythema  AuriculeE.  Catarrhalis. 

Inflammatio      Auriculas     Phlegmo-  Gonorrhoica. 

nosa.  Rheumatica. 

Pernio  Auriculsp,  a  frigore.  Arthritica,  s.  Otagra. 

Inflammatio  Meatus  Auditorii.  Scrophulosa. 


CLASSIFICATION    OF    AUKAL    AFFECTIONS. 


149 


Infiammatio  Membrana  Tympani      Otitis,  Syphilitica. 

(Myringitis).  Morbillosa. 

Middle    Ear. — Otitis   Universalis   s.  Scarlatiosa. 

totalis  interna.  Variolosa. 

Infiammatio  Tubse  Eustachianse  (Syr-  Eczematica  s.  Crusta  Lactea. 

(ingitis.)  Herpetica. 

His  second  division  includes — 

AFFECTIONS   CAUSED   BY   SOLUTIONS    OF   CONTINUITY. 


Contusio  Auriculas. 
Vulnera  Auriculse. 
Fractura  Auriculse.  *  . 
Vulnera  Membrana  Tympani. 

The  tliird  division  consists  of — 


Vulnera  Totalis  Auris. 

Coloboma  Auriculse. 

Foramina  Membrane  Tympani. 


AFFECTIONS   CAUSED   BY   COHESION    OF   PAETS. 


Dilatatio  Meatus  Auditorii. 

Strictura  Meatus  Auditorii. 

Compressio  s.  Thlipsis  Meatus 
Auditorii. 

Collapsus  Meatus  Auditorii. 

Atresia  s.  Obliteratio  Meatus  Audi- 
torii. 

Dilatatio  tubffi  Eustachii. 


Strictura  tubse  Eustachii. 
Obturatio  tubse  Eustachii. 
Collapsus  tubse  Eustachii. 
Obliteratio  tubse  Eustachii. 
Imperforatio  tubse  Eustachii. 
Aneurisraa  et  Varix  Auriculse. 
Cirsomyringa.' 


I  was  indebted  to  this  enumeration  of  Lincke's  for  the  first  account 
of  some  of  the  diseases  I  introduced  into  the  original  edition  of  the 
accompanying  Nosological  Table. 

In  Part  II.  of  my  Contributions  to  Aural  Surgery,  published  in 
1844,  I  gave  a  Nosological  Chart  of  Diseases  of  the  Ear,  "more  for 
the  purpose  of  eliciting  inquiry,  and  as  a  basis  for  future  investi- 
gations, than  as  possessing  any  great  merit  of  its  own."  The  general 
principles  upon  which  that  arrangement  was  based  I  still  adhere  to, 
viz. : — the  primary  divisions  into  the  diseases  of  the  auricle  and  exter- 
nal ear,  with  the  mastoid  and  pre-auricular  regions — in  fact,  all  the 
parts  visible  to  the  unassisted  eye,  or  which  can  be  appreciated  by 
the  touch ;  those  of  the  external  meatus  and  auditory  canal ;  the 
affections  of  the  membrana  tympani ;  those  of  the  middle  ear,  or  cav- 
ity of  the  tympanum ;  the  morbid  conditions  of  the  Eustachian  tube ; 


'  Handbuch  dor  theoretischen  und  practischen  Ohrenheilkunde, — von  Dr.  Carl  Gustav 
Lincke.  Zweiter  Band.  Die  Nosologie  und  Therapie  der  Ohrenkrankheiten.  Leipzig, 
1840.     Referred  to  at  page  42. 


150  CLASSIFICATION    OF    AURAL    AFFECTIONS. 

and  lastly,  tlie  diseases  of  the  internal  ear,  so  far  as  they  have  been 
recorded  by  authors  or  have  passed  under  my  own  observations- 
While,  however,  this  anatomical  division  serves  as  a  basis  for  the 
orders,  and,  to  a  certain  degree,  influences  the  division  into  genera, 
in  accordance  with  the  structure  affected,  it  is  not  possible,  consis- 
tently with  the  phenomena  of  disease,  to  carry  it  beyond  that  point, 
and  therefore  the  species  and  varieties  of  diseases  and  accidents  are 
not  confined  to  particular  structures,  but  are  classified  according  to 
their  symptoms  and  the  other  peculiarities  of  the  affections  them- 
selves. As  it  is  not  possible  to  limit  disease,  especially  of  an  inflam- 
matory character,  to  any  particular  structure,  so  is  it  impossible  to 
carry  the  anatomical  division  beyond  a  certain  extent. 

In  this  classification  I  have  inserted  some  congenital  malformations 
and  a  few  rare  diseases,  upon  the  authority  of  credible  authors,  but 
with  these  exceptions  they  have  passed  under  my  own  observation ; 
and  I  have  reduced  the  nomenclature  as  far  as  possible  to  English. 
The  chief  alteration  in  the  present  arrangement  consists  of  the 
position  .given  to  the  various  affections  producing  discharge  from  the 
meatus,  and  known  under  the  term  Otorrhoea,  which  I  have  distributed 
according  to  the  original  locality  or  structure  affected ;  but  owing  to 
the  great  importance  of  this  symptom,  its  frequency  in  these  coun- 
tries, the  variety  of  morbid  products,  even  in  remote  structures, 
which  it  may  produce,  and  the  fatal  results  which  sometimes  attend 
it,  I  have  devoted  a  separate  chapter  to  its  consideration.  The  num- 
ber of  inflammations  which  may  give  rise  to,  and  the  variety  of  struc- 
tures from  which,  discharges  from  the  ear  may  proceed,  either  origi- 
nally or  by  subsequent  extension,  prove  the  impossibility  of  retaining 
the  anatomical  division  beyond  a  certain  point.  There  are  some 
diseases  in  the  accompanying  table  which  belong  as  much  to  one 
division  as  another,  for  instance,  those  of  the  membrana  tympani; 
and  again,  there  are  others, — at  least  such  well-marked  symptoms  as 
to  have  acquired  the  names,  if  not  the  importance,  of  disease, — which 
it  is  difficult  to  place,  from  our  not  perfectly  understanding  where 
they  have  their  seat,  as  otalgia  and  tinnitus  aurium ;  but  these  are 
objections  to  which  every  synoptical  arrangement  must  be  liable. 


JS^OSOLOGICAL    TABLE    OF    AURAL    DISEASES. 


151 


DISEASES  OP   THE   AURICLE,  AND   THE   AURICULAR   REGIONS. 


Congenital    Maifokmations   and 
Diseases  of  the  Aueiclb. 


Wounds  and  Injuries. 


AlTEEATIONS    FKOM   PeESSUBE. 


TUMOES. 


Inflammation. 


Affections  of  the  Skin. 


Cancee. 


Affections  of  the  Mastoid  and 
Pee-Aueicular  Regions. 


f  Imperfect  or  irregular  development. 
I  Wanting. 
•{  Double. 
I  Cleft. 
I^Naevus. 

f  Incised  wounds. 
!  Lacerated  do. 
j  Contused    do. 
(^Fracture  of  cartilage. 

5  Flattening  and  obliteration  of  helix. 
(  Sloughing  and  gangrene. 

("Encysted. 
1  Steatomatous. 
•I  Synovial. 
j  Keloid  and  fibrous. 
l_  Hypertrophy  and  fatty  deposit. 

f  Phlegmonous — diffused  and  circumscribed. 
I  Erysipelatous — acute  and  chronic. 
<(  Exanthematous. 
I  Gouty. 
(_  Frostbites,  and  chilblain. 

C  Eczema. 
I  Herpes. 

Pemphigus. 

Syphilitic  ulceration. 
(_  Lupus. 


f  Inflammation  of  mastoid  periosteum, 
of  mastoid  gland. 

Chronic  abscess  on  mastoid  process. 
-   Aneurism. 

Caries  of  mastoid  process. 

Abscess  in  front  of  tragus. 

Mumps,  and  glandular  enlargements. 


DISEASES    OF   THE    EXTERNAL   MEATUS. 


Congenital  Malfoemations. 

Wounds  and  Injuries. 
FoKEiGN  Bodies  in. 

Diseases  of  Ceetjmenous  Glands. 


Inflammation. 


f  Meatus  wanting  in  bone  and  cartilage. 
I  double, 

-j  contracted  or  tortuous. 

I  closed  by  false  membrane. 

L  polypus  excresence  in. 

{See  Aueicle.) 


C  Increase  of  cerumen,  chronic  and  acute. 

<  Deficiency  of  cerumen. 

(  Alterations  in  quality  of  cerumen. 

C  Acute ;  circumscribed ; — abscess. 

I  Catarrhal  and  Chronic ; — Otorrhoea. 

I  Acute  diffused; — Otorrhoea. 

-\  Rheumatic. 

I  Exanthematous; — Otorrhoea. 

I  Gonorrhosal ; — OtorrhcEa. 

[_  Periosteal ; — OtorrhcEa  and  caries. 


152 


NOSOLOGICAL    TABLE    OF    AURAL    DISEASES. 


DISEASES   OF   THE   EXTERNAL   MEATUS — Continued. 


Affections  of  the  Skin. 


MoKBiD  Growths,  and  Altera- 
tions IN  Canal. 


Fistula. 

Caries. 

Malignant  Disease. 


(Eczema  and  herpes. 
Thickening  and  morbid  growth  of  cuticle. 
Piligrowth. 
Ulceration. 
f  Collapse. 
I  Stricture. 
Dilatation. 

Polypus  and  granulations. 
Exostosis. 
[_  Morula  and  condylomata. 


Osteosarcoma. 
Cancer  and  fungus. 


DISEASES    OF    THE    MEMBRANA   TYMPANI. 


Congenital  Malformations. 
Wounds  and  Injuries. 


Inflammation. 


Alterations  in  Cuticular  Later. 
Ulceration. 

Opacity  and  Morbid  Deposits  in. 
Alterations  of  Position. 


Wanting. 

Covered  by  false  membrane. 
Rupture. 

Mechanical  injury. 
Acute,  circumscribed; — abscess, 
diffused,  rheumatic. 

Exanthematous ; — Otorrhosa, 
GonorrhcBal ; — Otorrhoea. 
of  mucous  layer ; — Otitis. 
Subacute. 

syphilitic, 
strumous, 
typhoid. 
^  Chronic  granular  ;  — pannus. 
Eczema  and  herpes. 
Thickening  from  pressure. 
Perforation ; — OtorrhcEa. 
Total  destruction ; — Otorrh(Ea. 
Lymphy  effusions  and   thickening   of  middle 

layer. 
Atheromatous  and  calcareous  deposits. 
Collapsed  or  flat,  tympanum  open. 

Eustachian  tube  closed, 
from  adhesions  in  tympanum. 


DISEASES   OF   THE    CAVITAS   TYMPANI. 


Congenital  Malformation. 
Wounds  and  Injuries. 

Inflammation. 


f  Cavity  wanting ; — (osseous), 
j  filled  with  morbid  deposit, 

"j  Ossicula  wanting  or  misplaced. 
(_  Fenestra  wanting. 

Froin  fracture,  or  penetrating  instrument. 
'  Acute — Otitis ; — Otorrhoea. 

rheumatic ; — Otitis, 
with  paralysis  of  portio  dura. 
Subacute,  Catarrhal. 
Chronic,    with    thickening    of   the    membrane, 

membrana  tympani  perfect. 
Chronic,  the  cavity  exposed  from  perforation 

or  destruction  of  membrana  tympani. 
Periosteal ; — Otitis,  Otorrhoea,  disease  of  brain. 
Of  mastoid  cells. 


NOSOLOGICAL    TABLE    OF    AURAL    DISEASES. 


153 


DISEASES  OF  THE  CAVITAS  TYMPANi — Continued. 


Caries. 


Morbid  Gro'wths. 

Hemorrhage. 
Diseases  of  Ossicula. 


f  Polypus  and  granulations. 
I  Strumous  matter. 
-}  Fungus  haematodes. 
I  Osteosarcoma,  and  exostosis. 
1^  Ossification  of  fenestrse. 

C  Anchylosis. 
<  Displacement, 
r  Loss  of. 


DISEASES   OF   TEE   EUSTACHIAN   TUBE. 


Congenital  Malforjiatioxs. 
Foreign  Bobies  in. 

Infiammation. 
Obstruction. 


5  Wanting. 
\  Imperfect. 

C  Catarrhal. 

<  Chronic,  with  thickening  of  membrane. 
(  Syphilitic, 
f  From  stricture. 
J  Mucus. 

{  Thickened  and  relaxed  membrane, 

l^  Disease  of  throat  and  cleft  palate. 


DISEASES    OF   THE   LABYRINTH. 


Congenital  Malformation. 

Wounds  and  Injuries. 

Inflammation. 
Caries. 

Malignant  Growths. 

Tinnitus  Auriuji. 

Otalgia. 

Nervous  Deafness. 

Deaf-Dumbness. 


f  Labyrinth   wanting,   irregular,   or   imperfectly 
I       developed  in  some  of  its  parts. 
-j  Labyrinth  filled  with  caseous  matter. 
I  Labyrinthine  fluids  deficient, 
l^  Auditory  nerves  wanting  or  atrophied, 
r  Fracture,  with  serous  or  bloody  effusion. 
\  From  penetrating  instrument. 
Otitis; — OtorrhcEa;  cerebral  disease. 

5  Fungus  haematodes. 
\  Osteosarcoma. 
5  From  cerebral  disease. 
(  aural  disease. 

5  With  exaltation  of  hearing. 
\  Without  exaltation  of  hearing, 
r  From  cerebral  disease. 
\  disease  of  auditory  nerves. 

C  p  ■(■  1     5  From  malformation. 

<  (  Without  apparent  defect. 

t  Acquired. 


154 


CHAPTER    IV. 

DISEASES   OF   THE  AURICLE,   MASTOID  EEGION,   AND   EXTERNAL 

MEATUS. 

Anatomy  of  the  Auricular  Region :  the  Auricle  and  External  Auditory  Canal. — Con- 
genital Malformations  and  Diseases  of  the  External  Ear ;  Irregular  or  Imperfect  Deve- 
lopment.— Wounds  and  Injuries  of  the  Auricle. — Alterations  in  Form. — Morbid  Growths. 
— Inflammations. — Gout. — Cutaneous  Affections:  Eczema,  Herpes,  and  Pemphigus. — 
Cancer. — Affections  of  Mastoid  and  Auricular  Regions. — Post-aural  Tumors.' — -Disease  of 
Mastoid  Gland. — Inflammation  of  Periosteum. — Chronic  Abscess. — Aneurism. — Caries. 
— Cerebral  Otorrhosa. — Injuries  of  External  Meatus  :  Foreign  Bodies  in. — Diseases  of 
Cerumenous  Glands. — Inflammations :  Acute,  Chronic,  and  Specific. — External  Otor- 
rhosa.— Figtula  and  Caries. — Cutaneous  Diseases  ;  Piligrowth. — Morbid  Growths. — Poly- 
pus, Exostosis. — Alterations  in  Form  of  Canal. — Malignant  Diseases. 

It  is  not  my  intention  to  enter  minutely  or  at  any  length  upon  the 
subject  of  the  anatomy  of  the  organ  of  hearing,  but  simply,  to  preface 
the  description  of  the  diseases  of  each  particular  part  with  a  brief 
sketch  of  the  structures  which  those  diseases  engage,  in  order  to 
revive  in  the  memory  of  the  reader  some  general  knowledge  of  the 
parts  under  consideration. 

An  ear  consists  of  two  portions,  a  sensitive  and  a  mechanical ;  the 
latter  being  generally  subservient  to  the  former,  and  modified  ac- 
cording to  the  peculiar  habits,  exigencies,  and  mode  of  life  of  the 
different  classes  of  animals :  in  fishes,  cetacea,  and  amphibians,  to 
inhabit  the  water ;  in  birds  and  insects,  to  progress  through  the  air ; 
in  moles,  to  burrow  and  seek  their  food  under  the  ground ;  and  in 
man  and  other  terrestrial  animals,  to  walk  on  the  earth. 

The  human  ears  are  situated  in  the  temporal  bones,  one  on  each 
side  of  the  cranium.  Each  temporal  bone  consists  of  three  parts, — 
the  superior,  thin,  squamous,  or  scale-like  portion,  which  overlaps  the 
frontal  and  parietal  bones  upon  the  temporal  region,  but  which  is 
seldom  engaged  in  aural  diseases ;  the  mastoid,  or  posterior  inferior 
part,  thick  and  rough  for  the  attachment  of  muscles,  and  hollowed 
into  cells,  which  communicate  with  the  cavity  of  the  tympanum,  for 


ANATOMY  OF  THE  EXTERNAL  EAR.       ,  155 

the  purpose  of  increasing  the  surface  on  which  sound  acts ;  and  the 
petrous  portion,  so  named  from  its  stony  hardness,  which  passes 
inwards  from  the  junction  of  the  two  former  to  form  a  part  of  the 
lower  arch  or  base  of  the  skull ;  besides  various  processes,  the  chief 
of  which  are  the  zygomatic  and  the  styloid.  In  the  petrous  portion 
is  placed  the  special  organ  of  hearing.  Anatomists  have  divided  the 
ear  into  three  parts  :  the  internal,  or  labyrinth,  containing  the  expan- 
sion of  the  auditory  nerve,  and  including  the  cochlea,  vestibule,  and 
semicircular  canals;  the  middle,  or  cavitas  tympani,  enclosing  the 
chain  of  ossicles,  bounded  externally  by  the  membrana  tympani,  and 
internally  by  the  outer  wall  of  the  labyrinth,  communicating  poste- 
riorly with  the  mastoid  cells,  and  having  an  inferior  exit  through  the 
Eustachian  tube ;  and  the  external  ear,  consisting  of  the  meatus 
auditorius  externus,  and  the  pinna  or  auricle. 

Viewed  externally,  the  parts  which  become  concerned  in  diseases 
of  the  ear,  and  which  may  be  styled  the  aural  region,  are  contained 
within  that  space  between  the  malar  bone  in  front,  and  the  edge  of  the 
occipital  behind,  bounded  above  by  the  attachment  of  the  temporal 
muscle,  and  below  by  a  line  drawn  from  the  angle  of  the  jaw  to  the 
lower  margin  of  the  mastoid  process.  In  the  centre  of  this  lateral 
space  of  the  head  is  placed  the  auricle,  a  cartilaginous  projection, 
varying  in  size,  shape,  and  angle  of  attachment  in  different  races  of 
men,  as  well  as  in  different  individuals  ;  and  in  the  lower  animals  pre- 
senting all  those  modifications  applicable  to  their  respective  circum- 
stances and  habits  of  life,  with  which  every  one  is  familiar.  The 
human  ear  is  an  irregularly-curved  plate,  with  its  concavity  directed 
forwards  and  outwards.  It  consists  of  the  outer  fold  or  hem  turned 
over  on  itself,  and  called  the  helix,  broad  and  deep  in  front,  where  it 
rises  from  the  upper  boundary  of  the  external  meatus,  and  gradually 
becoming  narrow,  thin,  and  fleshy,  as  it  is  lost  in  the  lobe  behind  and 
below.  Its  size,  shape,  and  amount  of  overlapping  varies  con- 
siderably in  different  individuals,  and  in  many  persons  this  fold  is 
altogether  wanting,  particularly  posteriorly ;  we  also  frequently  find 
in  it  small  hard  nodules.  Within  the  helix  is  another  elevation,  de- 
nominated the  anti-helix,  of  a  somewhat  triangular  shape,  arising  in 
front  by  two  roots  from  behind  the  anterior  curvature  of  the  helix. 
Curving  upon  itself,  it  forms  the  superior  and  posterior  boundary  of 
the  concha,  and  ends  in  the  anti-tragus,  a  nipple-like  projection  from 
which  the  lobe  depends.  Between  the  eminences  of  the  helix  and 
anti-helix  runs  a  deep  groove,  called  the  navicular  fossa ;  while  the 


156  ANATOMY    OF    THE    AURICLE. 

space  between  the  roots  of  the  anti-helix  is — after  the  usual  fashion 
of  the  old  anatomists,  when  thej  had  exhausted  their  various  simili- 
tudes— called  the  fossa  innominata.  In  front  of  the  external  audi- 
tory aperture,  which  it  partially  overlaps,  and  arising  below  the  roots 
of  the  zygomatic  process,  is  a  concave  triangular  projection,  called 
the  tragus,  on  account  of  a  tuft  of  hair  resembling  a  goat's  beard, 
which  in  some  persons,  particularly  in  advanced  life,  grows  from  its 
tip.  Fronx  the  base  of  the  tragus  being  in  immediate  contiguity  with 
the  temporo-maxillary  articulation,  it  is  moved  by  the  action  of  the 
jaw,  particularly  in  eating.  The  cellular  and  adipose  substance  in 
front  of  its  anterior  edge  is  often  the  seat  of  inflammation,  and  hence 
arises  the  pain  experienced  in  such  cases  from  any  motion  of  the 
lower  jaw ;  and  the  temporal  artery  passing  through  this  space,  and 
there  giving  off  the  anterior  auricular,  may  account  for  the  unusual 
amount  of  throbbing  felt  in  abscess  of  this  region.  The  largest  con- 
cavity is  the  concha,  which,  leading  into  the  meatus  in  front,  forms 
posteriorly  the  hollow  of  the  external  ear,  and  is  bounded  above  by 
the  roots  of  the  helix  and  anti-helix,  behind  by  the  concave  margin 
of  the  latter,  and  below  by  the  anti-tragus  and  a  gutter-like  fossa, 
which  passes  downwards  somewhat  in  front  of  the  lobe.  The  concha 
is  generally  capacious  enough  to  contain  the  top  of  the  thumb.  All 
these  eminences  and  depressions,  as  well  as  the  posterior,  inferior, 
and  a  part  of  the  anterior  margin  of  the  meatus,  are  fashioned  out  of 
one  continuous  cartilage,  which  may  be  denominated  the  skeleton  of 
the  ear.  Pendant  from  the  lower  edge  of  this  cartilage  is  the  lobe, 
a  fleshy  projection,  more  or  less  long  and  thick  in  different  individuals, 
and  passing  off  anteriorly  into  the  integuments  of  the  cheek  beneath 
the  tragus.  It  contains  a  quantity  of  cellular  and  some  adipose 
tissue,  and  is  very  extensile,  as  may  be  seen  in  inflammations,  dropsy, 
and  emphysema,  &c.  From  time  immemorial,  and  among  all  nations, 
this  part  has  been  adorned. 

The  cartilaginous  portion  of  the  ear  is  invested  with  a  strong  peri- 
chondrium, and  the  Ayhole  is  covered  with  an  envelope  of  fine  integu- 
ment, highly  vascular  and  sensitive,  so  as  to  be  even  susceptible  of 
blushing  and  other  peculiar  impressions  consequent  upon  mental  emo- 
tion. It  contains  many  sebaceous  follicles,  particularly  in  the  concha, 
where  they  sometimes  become  enlarged,  and  present  those  dark  worm- 
like bodies  with  which  every  one  is  familiar.  In  some  adults  the 
auricle  has  a  thick,  leathery  feel,  and  it  is  often,  even  in  the  normal 
state,  of  a  bluish  purple  color.     Even  in  some  new-born  children  we 


ANATOMY    OF    THE    AURICLE.  157 

observe  hair  growing  from  the  upper  margin  of  the  helix,  and  in 
several  hirsute  males  in  middle  life  this  is  a  common  place  for  tufts  of 
hair  to  project  from,  as  well  as  from  the  anterior  surface  of  the  lobe, 
the  tragus,  and  the  anti-tragus.  The  hairs  growing  from  these  parts 
and  around  and  within  the  external  meatus,  though  short,  are  gene- 
rally very  stiff,  like  the  eyebrows  of  some  aged  persons,  and  often 
become  a  source  of  annoyance  either  by  being  entangled  with  the 
cerumen,  or  by  falling  inwards,  and  irritating  the  membrana  tympani. 

The  auricle  is  attached  by  ligaments,  muscles,  and  the  common 
integuments,  to  the  skull,  and  by  dense  ligamento-cellular  membrane 
to  the  anterior,  inferior,  and  posterior  margin  of  the  meatus,  extend- 
ing from  the  root  of  the  zygoma  to  the  mastoid  process.  Among 
civilized  nations  this  part  is  not  so  well  developed,  does  not  stand  out 
at  the  same  angle  from  the  head,  and  its  muscular  apparatus  is  not 
so  much  called  into  action  as  in  savage  people,  whose  means  of  safety 
or  subsistence  depend  to  a  certain  extent  on  their  powers  of  hearing. 
Any  one  who  observes  the  ears  of  a  grayhound,  when  that  animal's 
attention  is  specially  engaged,  may  form  some  idea  of  the  beautiful 
muscular  apparatus  which  an  ear  in  its  natural  condition  possesses. 
Still,  we  often  meet  persons  who  have  the  power  of  moving  the  exter- 
nal ear  in  different  directions,  principally  upwards,  backwards,  and  a 
little  forwards. 

Two  sets  of  muscles  have  been  described  as  belonging  to  the  human 
ear,  but  in  the  great  majority  of  individuals  they  are  either  rudimen- 
tary or  are  altogether  wanting.  The  first,  or  the  extrinsic,  are  those 
which,  attached  to  the  head,  move  the  external  ear  as  a  whole ;  the 
second,  or  the  intrinsic  muscles,  arising  from  particular  portions  of 
the  cartilage,  and  inserted  into  other  parts  of  the  same  structure, 
serve  to  increase  its  various  concavities,  and  doubtless,  when  well 
developed,  they  assist  to  render  the  external  ear  at  particular  times 
a  better  collector  and  conductor  of  sound.  Besides  these  muscles, 
certain  fissures,  described  by  Santorini,  traverse  the  base  of  the  car- 
tilage near  its  attachment,  particularly  where  it  forms  the  anterior 
triangular  wall  of  the  flexible  portions  of  the  meatus, — which  are  sup- 
posed to  contain  muscular  fibres,  capable  of  shortening  that  passage. 
It  is  said  that  the  tyrant  Dionysius  had  a  subterranean  chamber  con- 
structed in  the  shape  of  the  human  ear,  which  was  in  connexion  with 
an  adjoining  prison,  and  which  he  employed  for  the  purpose  of  trans- 
mitting whatever  was  said  by  those  confined  therein. 

The  size  and  form  of  the  external  ear  have  been  justly  considered 


158       ANATOMY  OF  THE  EXTERNAL  MEATUS. 

characteristic  of  beauty  and  breeding ;  and  tbe  national  peculiarities 
of  this  feature  are  not  unworthy  of  attention,  as  also  its  figure  and 
position  in  some  of  the  bygone  races.  Those  familiar  with  ancient 
sculpture  and  painting,  particularly  among  the  Oriental  monuments, 
must  have  observed  many  varieties  of  it.  It  has  been  stated  that  in 
the  ancient  inhabitants  of  Egypt  the  ear  was  placed  unusually  high ; 
I  have  examined  a  great  number  and  variety  of  the  crania  of  that 
people,  and  I  have  not  found  the  external  meatus  misplaced ;  but  in 
the  paintings  and  statues  the  auricle  appears  to  be  prolonged  up- 
wards. This  peculiarity  is  more  noticeable  among  the  Asiatic  races, 
strangers,  slaves,  and  captives,  than  in  the  true  natives  of  the  land, 
as  may  be  seen  from  Rossilinni's  faithful  illustrations  of  the  ancient 
Egyptian  paintings.  My  late  esteemed  friend,  the  talented  S.  G. 
Morton,  of  Philadelphia,  has  given  some  notices  of  the  external  ear 
in  his  valuable  ethnological  writings. 

The  mastoid  region  may  be  defined  as  all  that  semilunar  space,  for 
the  most  part  uncovered  by  hair,  behind  and  partially  overlapped  by 
the  auricle.  Beneath  the  delicate  skin  of  this  part  we  often  meet 
one,  sometimes  two,  small  glands,  lying  parallel  with  the  posterior  at- 
tachment of  the  auricle ;  there  is  then  a  strong  fascia  covering  the 
tendinous  expansion  of  the  sterno-mastoid  muscle,  and  finally  the 
periosteum.  The  posterior-auricular  branch  of  the  occipital  artery 
runs  close  to  the  junction  of  the  auricle  and  scalp,  and  its  position 
should  be  borne  in  mind  in  making  incisions  in  this  spot. 

The  meatus  auditorius  externus  exhibits  greater  variety  in  length, 
shape,  and  direction  than  works  on  anatomy  would  lead  us  to  believe. 
It  is  an  irregularly  curved  tortuous  tube,  wider  at  the  extremities  than 
near  the  middle — from  an  inch  and  a  quarter  to  an  inch  and  a  half  in 
length — ovoid  in  calibre  externally,  but  becoming  circular  towards  its 
distal  end :  and  leading  from  the  concha  externally,  at  first  a  little 
forwards  and  upwards,  then  backwards  and  inwards,  and  again  turn- 
ing downwards,  forwards,  and  iuAvards,  to  the  membrana  tympani, 
which  separates  it  from  the  middle  ear.  Owing  to  the  oblique  posi- 
tion of  this  membrane,  the  depth  or  curvature  of  the  glenoid  cavity, 
and  also  from  the  cartilage  beneath  being  more  complete,  and  pro- 
longed inferiorly,  the  roof  of  the  external  meatus  is  somewhat  shorter 
than  its  floor.  It  is  only  by  constant  inspection,  and  also  examining 
a  number  of  casts  of  this  passage,  that  we  can  understand  its  bear- 
ings and  different  curves.  Independent  of  the  oblique  position  from 
above  downwards  of  the  membrana  tympani,  there  is  a  very  well- 


ANATOMY  OF  THE  EXTERNAL  MEATUS.       159 

marked  obliquity  presented  by  tlie  tympanal  end  of  the  bony  meatus, 
which  spreads  forwards  and  downwards  behind  the  glenoid  cavity, 
where  the  bone  is  remarkably  thin,  and  sometimes  perforated  with 
small  apertures.  It  is  difficult  to  bring  this  portion  into  view  in  the 
living  state,  but  it  is  frequently  the  seat  of  polypus,  which,  when  of  a 
small  size,  often  lies  concealed  therein,  and  keeps  up  discharge  long 
after  the  rest  of  the  canal  has  assumed  a  healthy  character.  It  is 
best  seen  from  within,  by  making  a  section  of  the  bone  behind  the 
groove  for  the  attachment  of  the  membrana  tympani.  The  bony 
meatus  is  about  three-quarters  of  an  inch  in  length ;  its  outer  margin, 
particularly  below,  from  the  root  of  the  zygoma  to  the  mastoid  pro- 
cess, is  rough  for  the  attachment  of  the  auricle,  which  is  fixed  to  it 
by  strong  fibro-ligamentous  material.  The  external  third  or  more  of 
the  meatus  auditorius  externus  is  formed  partly  of  cartilage  and  partly 
of  fibro-cellular  tissue,  and  it  is  this  portion  alone  which  is  capable  of 
dilatation  even  to  a  slight  extent,  but  being  susceptible  of  considerable 
motion,  it  can  be  so  far  straightened  as  to  permit  a  direct  stream  of 
light  to  pass  in  through  the  immovable  bony  portion  to  the  membrana 
tympani.  The  anterior  outer  wall  of  the  external  meatus,  formed  by 
a  triangular  portion  of  cartilage  within  and  below  the  tragus,  is  influ- 
enced by  the  action  of  the  condyle  of  the  jaw,  as  may  be  perceived 
by  placing  the  point  of  the  finger  within  the  meatus,  and  then  open- 
ing and  shutting  the  mouth.  In  cases  of  inflammation  of  the  passage, 
the  motion  of  the  jaw,  as  also  sneezing  or  coughing,  causes  on  this 
account  great  pain  and  distress.  The  parotid  gland  also  coming  up 
thus  far,  and  surrounding  the  lower  and  part  of  the  anterior  wall  of 
the  meatus,  causes,  when  inflamed,  pain  in  the  ear  and  deafness.  The 
periosteum  and  perichondrium — the  former  of  which  is  remarkably 
delicate — are  covered  by  a  reflection  of  the  cutis  from  the  auricle, 
which  is  remarkably  fine  and  vascular  where  it  lines  the  osseous  por- 
tion, and  its  cuticular  layer  is  reflected  over  the  external  surface  of 
the  membrana  tympani.  This  cuticular  lining  is  susceptible  of  con- 
siderable thickening  either  by  pressure  or  inflammation,  often  present- 
ing a  macerated  appearance  :  and  in  the  dead  subject  it  can  sometimes 
be  drawn  out  entire,  like  the  finger  of  the  glove. 

Within  the  external  margin  of  the  passage,  and  in  some  persons  as 
far  in  as  the  junction  of  the  osseous  meatus,  there  are  a  number  of 
fine  hairs,  styled  \ibrissge,  which,  all  pointing  towards  the  centre  of 
the  canal,  serve  to  exclude  insects  or  extraneous  bodies,  but  which,  in 


160     MALFORMATIONS  OF  THE  EXTERNAL  EAR. 

cases  of  impaction  of  the  canal  with  wax,  act  like  so  many  nails  to 
retain  the  offending  plug  in  situ. 

Imbedded  in  the  integument  of  the  meatus,  chiefly  in  the  membra- 
nous portion,  and  most  abundant  posteriorly,  we  find  the  cerumenous 
glands  of  Wharton ;  as  a  whole  resembling  a  ring  with  the  setting 
behind, — each  gland  being  somewhat  the  shape  of  a  Florence  oil- 
flask.  These  secrete  the  substance  so  well  known  as  cerumen  or  ear- 
wax,  of  a  brownish  yellow  color,  adhesive,  bitter,  ignitable,  composed 
of  a  peculiar  animal  matter  resembling  wax,  lactate  of  potash,  and 
some  lime.  There  can,  I  think,  be  little  doubt  that  the  ear-wax  exer- 
cises some  useful  influence  in  perfecting  the  external  auditory  passage 
as  an  acoustic  instrument,  as  well  as  serving  to  exclude  insects.  It 
is  frequently  deficient,  or  altogether  wanting,  in  cases  of  long-con- 
tinued deafness,  so  that  it  is  generally  believed  to  be  one  of  the  causes 
of  defective  hearing,  and  various  nostrums  are  still  in  use  for  promoting 
its  secretion.  I  believe  that  the  true  cause  of  its  deficiency  consists 
in  inflammation  of  the  glands  from  which  it  is  secreted,  or  of  the 
structui;es  in  which  they  are  placed.  I  have  examined  numbers  of 
the  congenitally  deaf  and  dumb,  in  whom  the  secretion  was  quite 
abundant ;  and  I  have  even  seen  it  accumulate  in  these  persons,  and 
produce  such  uneasiness  as  to  require  removal. 

MALFORMATIONS  OF  THE  EXTERNAL  EAR. 

The  temporal  bone  as  a  whole  is  never,  that  I  have  heard  of,  want- 
ing, but  great  variety  exists  with  regard  to  its  different  parts,  each  of 
which  presents  congenital  abnormities,  which  shall  be  considered  in 
detail.  The  external  contour,  particularly  of  the  squamous  portion, 
is  very  variable,  and  seems  to  assume  a  special  or  fixed  character  in 
different  races  of  mankind.  There  is  in  the  College  of  Surgeons  in 
Dublin  the  deformed  skull  of  a  boy  aged  16,  who,  I  understand,  died 
in  one  of  our  prisons  while  under  sentence  of  transportation,  in  which 
the  left  side  is  quite  flat,  and  there  is  no  trace  of  squamous  suture. 
Upon  examining  the  cranium  one  cannot  help  asking, — Would  not 
that  poor  boy  have  been  a  more  suitable  inmate  for  a  lunatic  asylum 
than  a  convict  prison  ? 

The  auricle  is  not  fully  developed  until  the  sixth  month,  and  is  that 
portion  of  the  auditory  apparatus  most  liable  to  variety  and  irregularity. 
Its  peculiarities  are  sometimes  so  very  slight,  that  those  only  who 
are  in  the  habit  of  examining  ears  daily  can  perceive  any  difference 


MALFORMATIONS  OF  THE  EXTERNAL  EAR.     161 

from  the  normal  condition  of  this  portion.  The  size  and  shape  of 
the  whole  auricle  is  very  various  in  diiferent  families  and  individuals. 
The  helix  is,  as  already  stated,  often  wanting ;  the  lobe  still  more  fre- 
quently. The  concha,  instead  of  being  a  concavity,  is  sometimes  a 
convexity.  The  amicle  is  sometimes  represented  by  a  mere  fold  of 
skin ;  I  saw  such  a  case  in  consultation  with  Dr.  Forrest  some  years 
ago  ;  it  occurred  in  an  infant,  and  only  existed  on  one  side.  Instances 
have  been  recorded  of  the  total  absence  of  the  auricle,  yet  it  is  said 
the  persons  heard  well.  Schmalz,  in  his  Beitrcige  zur  Crehor  und 
SprachSeilkunde,  1846,  has  figured  three  cases  of  congenital  de- 
formity of  the  auricle,  in  the  most  remarkable  of  which  there  was  no 
external  meatus,  and  the  upper  portion  of  the  helix  alone  was  nor- 
mal. This  part  has  also  been  found  cleft.  A  plm-ality  of  auricles 
has  been  remarked.  Cassebohm  relates  the  case  of  a  child  with  four 
ears,  two  naturally  placed,  and  two  lower  down  on  the  neck  ;  there 
were  in  that  instance  two  petrous  portions  to  each  temporal  bone. 
Fom-  auricles  are  not  uncommon  among  some  of  the  lower  animals, 
swine  in  particular :  the  old  Irish  pig,  with  long  legs,  high  back,  and 
narrow  snout,  had  very  frequently  supernumerary  auricles,  small  and 
misshapen,  situated  low  down  on  the  neck.  Sheep  have  sometimes 
four  ears.  Professor  A.  Thompson  has  given  a  "  notice  of  several 
cases  of  malformation  of  the  external  ear,"  in  the  Edinburg  Monthly 
Journal,  but  his  description  is  rather  unsatisfactory,  inasmuch  as  in 
the  first  case,  that  of  W.  B.,  the  peculiar  malformation  of  the  auricle 
is  not  specified ;  in  the  second  case,  that  of  a  young  lady  at  Falkirk, 
she,  he  states,  presented  "  the  same  kind  of  malformation  to  a  greater 
extent  than  in  W.  B. ;  and  along  with  the  local  malformation  of  the 
ear,  considerable  imperfection  in  the  lower  part  of  the  face;"  and  in 
the  third  case,  that  of  Miss  R.,  "  the  form  of  the  imperfectly  deve- 
loped auricles,  and  the  shape  of  the  countenance,  presented  a  remark- 
able similarity  to  those  of  the  girl  at  Falkirk." — See  Numbers  for 
December,  1846,  and  April,  1847. 

The  same  essay  contains  some  remarks  upon  the  causes  of  muteism, 
which  I  cannot  refrain  from  adverting  to  here.  "  The  instances,"  he 
says,  "  are  extremely  rare,  however,  in  which  deaf-dumbness  is  caused 
by  congenital  malformation  of  any  kind,  and  it  is  sufficiently  well 
known  to  all  those  who  have  been  connected  with  institutions  for  the 
deaf  and  dumb,  that  in  by  far  the  greater  number  of  instances  of 
deafness,  either  total  or  to  such  a  degree  as  to  induce  dumbness,  the 
afi'ection  has  proceeded  from  diseases  in  early  life,  such  as  scarlet  fever, 

11 


162  MALrORMATIOJfS     OF    THE     EXTERNAL     EAR. 

measles,  and  small-pox;  the  inflammatory  and  suppurative  process 
affecting  first  the  cavity  of  the  tympanum,  and  being  subsequently 
communicated  to  some  part  of  the  labyrinth."  Surely  the  Professor 
cannot  have  examined  any  of  the  works  treating  of  muteism,  or  he 
would  have  been  aware  of  the  well-established  fact,  that  in  every 
country  in  which  the  subject  has  been  carefully  examined,  and  faith- 
ful statistics  collected,  the  number  of  the  acquired  cases  of  deaf- 
dumbness  is  about  one-eighth  of  the  whole.  A  case  has  been  related 
in  which  the  auricle  consisted  in  a  fold  of  integument  perforated  with 
two  apertures,  and  with  the  concavity  turned  towards  the  head.  The 
auricle  is  sometimes  the  seat  of  congenital  ngevus,  either  alone  or  in 
connexion  with  the  same  disease  in  the  neighboring  parts.  In  1810 
the  late  Professor  Colles  tied  the  posterior  auris  for  aneurism  by 
anastomosis  of  the  auricle. 

Congenital  malformations  and  abnormal  peculiarities  of  the  exter- 
nal meatus  and  auditory  canal  are  by  no  means  uncommon  ;  the  pas- 
sage is  frequently  smaller,  and  often  more  tortuous  than  natural,  and 
it  has  been  found  closed  with  a  polypus  excrescence  at  birth.  There 
is  great  variety  in  the  length,  calibre,  and  curvatures  of  the  sides  of 
the  external  auditory  passage  among  different  persons, — perhaps  just 
as  much  as  there  is  in  the  shape  of  the  nose,  the  auricle,  or  any  other 
feature  of  the  face.  I  had  no  idea  how  much  diversity  existed  in  the 
auricle  until  I  began  to  study  diseases  of  the  ear ;  and  latterly  I  have 
so  frequently  observed  congenital  peculiarities  and  malformations  of 
the  auricle  in  persons  who  have  applied  for  advice  on  account  of  some 
aural  disease,  that  I  have  been  forced  to  the  conclusion,  either  that 
these  peculiarities  occur  much  more  frequently  than  is  supposed,  or 
that,  in  some  way  which  is  at  present  unaccountable,  persons  possess- 
ing such  peculiarities  are  more  subject  to  aural  diseases  than  the  rest 
of  the  community. 

I  have  met  with  cases,  both  in  children  and  adults,  in  which  the 
external  auditory  canal  would  not  admit  anything  larger  than  the 
end  of  an  ordinary  dressing-probe.  I  have  also  seen  an  hour-glass 
contraction  in  the  centre  of  the  passage,  which,  although  it  had  never 
impaired  the  hearing,  was  yet  a  considerable  impediment  to  the  re-' 
moval  of  some  hardened  wax  which  had  accumulated  behind  it.  The 
external  meatus  is  sometimes  preternaturally  wide.  The  meatus  has 
been  found  double ;  the  supernumerary  canal  opening  behind  the  auri- 
cle. False  membranes  stretching  across  the  meatus  have  been  re- 
corded by  many  observers ;  and  such  cases  are  susceptible  of  relief 


MALFORMATIONS  OF  THE  EXTERNAL  EAR.     163 

by  surgical  operation,  althougli  considerable  difficulty  is  always  ex- 
perienced in  keeping  open  the  newly-formed  aperture.  Several  cases 
have  been  noted  of  imperforate  meatus  with  and  without  any  abnor- 
mal condition  of  the  auricular  cartilage.  Sometimes  the  place  of  the 
external  aperture  is  merely  marked  by  a  slight  depression  in  the  skin, 
at  others  the  membranous  portion  of  the  canal  is  perfect,  but  beyond 
that  all  is  solid  bone.  I  have  met  with  three  such  cases  :  one  was  a 
boy  six  years  of  age,  laboring  under  ottorrhoea  on  the  left  side  ;  upon 
the  right  the  membranous  portion  of  the  canal  was  perfect,  but  the 
osseous  part  was  closed  by  firm  bone,  covered  by  a  thin  layer  of  inte- 
gument. The  second  was  in  a  woman,  aged  30,  born  deaf  and  dumb ; 
there  was  no  osseous  canal  on  either  side.  The  third  case  was  as 
follows : — 

A  female,  aged  20,  applied  at  the  hospital  on  account  of  ottorrhoea 
of  the  left  side.  On  examination,  I  found  the  right  auricle  normal, 
but  the  meatus  ended  in  a  shallow  cut  de  sac,  lined  by  smooth,  white 
membrane,  which  just  admitted  the  end  of  the  little  finger.  She  was 
completely  deaf  on  that  side,  but,  strange  to  say,  until  she  had  the 
inflammation  and  ottorrhoea  of  the  other,  she  was  quite  unconscious  of 
her  imperfection.  How  frequently  do  we  meet  with  instances  of  total 
blindness  of  one  eye,  evidently  congenital,  discovered  by  the  merest 
accident  long  after  birth.  Although  the  bottom  of  the  shallow  cavity 
in  this  case  felt  and  sounded  solid,  I  determined  upon  exploring  it, 
and  made  upon  two  occasions  a  crucial  incision ;  but  all  behind  the 
membrane,  which  appeared  to  be  a  thin  layer  of  cartilage  covered 
with  fine  integument,  was  perfectly  solid.^ 

*  [Prof.  Miissey  has  recorded  in  the  American  Journal  of  Medical  Science,  vol.  xxi.  p. 
378  (for  1837),  an  exceedingly  interesting  case  of  congenital  "absence  of  the  Meatus 
Auditorius  externus  of  both  ears  without  much  impairing  the  hearing."  The  subject  of 
this  history  was  a  bookseller  in  the  State  of  Vermont  aged  27.  Both  auricles  were 
smaller  than  natural,  particularly  the  right,  and  but  imperfectly  developed.  There  was 
no  vestige  of  either  meatus ;  not  even  an  indentation.  The  whole  ear  was  covered  by 
a  continuation  of  the  integuments.  No  orifice  could  be  detected  "by  moving  the  auri- 
cles from  side  to  side  and  attempting  to  depress  the  skin  in  the  situation  of  the  usual 
orifice."  His  hearing  was  too  obtuse  for  low  conversation,  yet  sufficiently  good  to  prose- 
cute his  business.  It  was  equally  good  on  both  sides,  "and  sounds  from  behind  were 
quite  as  readily  appreciated  as  those  from  in  front  and  on  either  side."  As  "  he  could 
hear  with  equal  readiness  when  the  lips  and  nose  were  closed  as  when  both  were  wide 
open,"  and  as  Prof  Mussey  failed  after  several  efforts  to  introduce  a  probe  "  as  far  as 
usual"  into  the  Eustachian  tube,  he  inferred  that  that  "  tube,  if  its  guttural  orifice  ex- 
isted, had  no  communication  with  the  cavity  of  the  tympanum."  By  '•  covering  the 
hairy  scalp,  except  a  small  portion  at  the  anterior  and  upper  part,  leaving  the  face  and 


164  INJURIES    OF    AURICLE. 

WOUNDS    AND    INJURIES    OF    THE    AURICLE. 

These  injuries,  either  from  accident  or  design,  are  not  as  frequent 
in  this  country,  nor  indeed  any  other,  as  in  former  days.  "  Cropping 
the  ears"  was,  in  the  time  of  the  civil  wars,  not  an  unusual  punish- 
ment, and  it  is  still  resorted  to  in  some  Eastern  countries.  I  remem- 
ber a  baker  in  Cairo  being  nailed  by  the  ear  to  his  own  door  for  sell- 
ing bread  beneath  the  standard  weight.  The  punishment  was  a  very 
severe  one,  as  the  man's  toes  scarcely  touched  the  ground.  I  suppose 
"nailing  the  ear  to  the  pump"  was,  from  the  popular  adage,  a  com- 
mon form  of  punishment  in  other  days.  Splitting  or  cutting  oiF  the 
ears  was  a  cruel  mode  of  maiming  and  ill-treatment  resorted  to  by 
the  insurgents  in  this  country  formerly ;  yet  we  read  in  history  of 
celebrated  generals  forwarding  to  their  sovereigns  the  ears  of  the  van- 
quished, as  trophies  of  conquest.  Having  had  an  opportunity  of 
examining  many  of  the  wounded  French  soldiers  after  the  battle  of 
Constantina,  I  was  struck  with  the  number  of  sword-gashes  about  the 
head  an4  face,  and  of  the  auricle  in  particular.  I  was  informed  they 
were  inflicted  by  the  yataghan,  the  mode  of  using  which,  somewhat 
after  the  fashion  of  carving  a  round  of  beef,  may  explain  the  way  in 
which  these  wounds  were  inflicted.  In  Germany  when  sword-duels 
were  common  among  the  students,  surgeons  had  considerable  practice 
in  simple  incised  wounds  of  the  ear.  Instances  have  been  related  of 
adhesion  having  taken  place  even  after  the  part  had  been  completely 
removed.  Writers  seem  to  be  averse  to  the  employment  of  sutures, 
but  we  have  not  in  these  kingdoms  much  experience  of  the  matter. 
The  application  of  lint,  spread  with  white  of  egg,  so  as  to  keep  the 
parts  in  strict  apposition,  I  have  seen  used  with  advantage.  A  cork 
pad,  accurately  adjusted  to  the  space  between  the  posterior  surface  of 
the  auricle  and  the  mastoid  region,  has  been  recommended,  but  the 
ingenuity  of  the  surgeon  will,  I  think,  without  adhering  to  any  defi- 
nite rules,  generally  enable  him  in  every  case  to  adapt  the  means  to 
the  end.  I  have  seen  the  auricle  lacerated  and  contused  by  pressure 
against  a  wall,  by  falls,  and  by  the  transit  of  a  cart-wheel ;  and  in 
the  days  of  faction  fights  in  Ireland,  I  have  dressed  many  dozen  au- 

ears  bare,"  with  a  layer  of  cloth,  the  hearing  was  "  depressed  in  a  marked  degree," 
much  more  than  by  "  covering  the  face  and  ears,  leaving  out  the  scalp."  Thus  showing 
the  influence  of  the  cranial  bones  in  conducting  sonorous  undulations  to  the  auditory 
nerve.  A  conducting  rod  placed  over  the  mastoid  made  the  hearing  better  than  when 
placed  at  any  other  point — A.  H.] 


INJURIES     OF     AURICLE.  165 

ricles  split  and  bruised  by  blackthorn  sticks,  and  have  often  wondered 
at  the  small  amount  of  injury  or  deformity  which  follows  such  injuries. 
Frajcture  of  the  cartilage  has  taken  place  from  suddenly  and  violently 
doubling  up  the  ear. 

The  operation  of  piercing  the  lobe  for  the  introduction  of  ear-rings, 
either  as  a  sanitary  measure,  or  for  ornament,  so  common  among  all 
nations,  is  not  always  unattended  with  unpleasant  consequences.  I 
have  seen  it  give  rise  to  erysipelatous  inflammation,  to  eczematous 
eruptions  spreading  over  the  side  of  the  face,  and  also  to  abnormal 
growths  in  the  lobe.  Piercing  is  usually  performed  with  a  sharp  awl 
pressed  through,  against  a  cork  held  at  the  back  of  the  lobe,  by  the 
Jewellers,  and  those  who  dispose  of  the  wares,  ornamental  or  medi- 
cinal, to  be  inserted  therein. 

The  skin  of  the  auricle  is,  as  already  stated,  highly  sensitive.  Peo- 
ple speak  of  "blushing  to  the  ears,"  because  that  part  becomes  red 
and  hot  upon  mental  emotion.  Besides  this,  there  are  many  popular 
adages  relating  to  this  part.  We  have  all  felt  one  or  both  ears  unac- 
countably hot,  and  apparently  swollen  at  particular  times.  If  the 
left  ear  is  red,  it  is  said  "  somebody  is  speaking  well  of  you,"  but  if 
the  right,  the  contrary.  When,  according  to  the  Mosaic  law,  a  bonds- 
man's term  of  servitude  had  expired,  and  that  from  affection  to  his 
master  he  desired  to  remain,  the  owner  was  directed  to  "  take  an  awl 
and  thrust  it  through  his  ear  unto  the  door :  and  he  shall  be  thy 
servant  for  ever" — Deut.  xv.  ver.  17  ; — and  my  friend.  Dr.  Carter,  has 
informed  me,  that  whenever  a  negro  in  the  West  Indies  wishes  to 
attach  to  himself  a  dog,  he  nails  his  ear  for  a  day  to  the  door-post  of 
his  cabin.  The  state  of  the  auricle  is  said  to  be  characteristic  of 
disease  in  other  organs ;  it  is  red  in  congestion  of  the  head ;  livid  in 
diseases  of  the  circulating  system ;  and  cold,  thin,  and  insensible  in 
nervous  deafness,  or  in  diseases  of  the  internal  ear.  Pulling  chil, 
dren's  ears  is,  I  have  no  doubt,  conducive  to  inflammatory  affections- 
both  in  the  auricle  and  meatus.  Boys  increase  the  angle  of  the  auri- 
cle, and  give  themselves  what  are  called  "  dog's  ears,"  by  pulling 
down  their  hats  or  caps ;  and,  on  the  other  hand,  old  women,  from 
having  tied  up  the  auricle  for  many  years,  have  so  squeezed  and  flat- 
tened this  part,  that  it  lies  close  to  the  head,  and  the  various  curva- 
tures, particularly  of  the  helix,  are  obliterated.  Sloughing  and  gan- 
grene may  ensue  from  long-continued  pressure  during  lingering  illness, 
or  from  exposure  and  want  of  due  circulation,  as  in  fever,  when  the 
extremities  at  times  mortify. 


166  TUMORS     OF    THE     AURICLE. 

Baron  Larrey's  work,  alluded  to  at  page  48,  contains  some  valu- 
able observations  upon  wounds  of  the  auricle,  and  the  mode  of 
treating  them.  Among  other  matters  he  mentions  a  case  worthy 
of  consideration  in  a  medico-legal  point  of  view.  An  officer  of  the 
French  army  stated  that  he  was  attacked  by  a  stranger,  who  cut  off 
his  ear,  but  Larrey,  on  examining  the  wound,  discovered  that  it  had 
been  done  by  the  teeth.  He  also  mentions  the  case  of  a  soldier, 
whose  meatus  had  been  grazed  by  a  musket-ball,  and  the  parts  adher- 
ing subsequently,  the  external  aperture  was  thus  hermetically  closed 
by  the  cicatrix.  As  the  man's  hearing  remained  perfect,  this  case 
attracted  great  attention,  and  he  was  introduced  at  one  of  the  meet- 
ings of  the  Philomathic  Society,  in  the  winter  of  1815-16,  as  a  sin- 
gular instance  of  the  preservation  of  hearing  after  he  had  "  lost,  ac- 
cording to  his  own  statement,  several  small  pieces  of  the  meatus  itself, 
besides  all  the  small  bones  of  the  ear !"  No  doubt  a  French  soldier 
is  a  very  intelligent  person,  but  whether  his  word  should  have  been 
taken  by  the  Savans  with  respect  to  the  loss  of  the  ossicula  auditus 
is  questionable ;  and  whether  the  Baron  should  have  published  the 
case  as  a  "  surprising  circumstance,"  without  having  made  some  at- 
tempt to  explore  the  state  of  the  membrana  tympani  by  dividing  the 
external  cicatrix,  is  still  more  so.  I  mention  the  case,  however,  in 
order  to  show  the  looseness  which  prevailed  among  medical  writers, 
even  of  the  first  eminence,  with  respect  to  diseases  of  the  ear,  twenty 
years  ago. 

TUMORS   OF  THE   AURICLE. 

Morbid  growths  of  the  auricle  are  by  no  means  uncommon :  stea- 
tomatous  and  sebaceous  bodies  form  in  the  concha ;  I  have  three  times 
removed  firm,  encysted  tumors,  each  the  size  of  a  hazel  nut,  from 
the  posterior  end  of  the  helix.  Hypertrophy  of  the  lobe  has  proceeded 
to  such  an  extent  as  to  reach  to  the  neck.  Boyer,  in  his  Treatise  on 
Surgical  Diseases,  has  related  the  case  of  a  large  pendulous  lobe  of 
that  description,  which  he  removed.  The  following  case  of  fibrous 
tumor  of  the  lobe,  No.  19  in  the  Registry,  is  a  good  example  of 
its  kind. 

M.  S.  a  female,  aged  19,  has  a  hard,  firm,  ovoid  tumor,  occupying 
the  centre  of  the  lobe  on  each  side,  but  largest  on  the  left — of  which 
the  accompanying  woodcuts  afford  faithful  representations.  It  is  of 
a  stony  hardness,  and  is  quite  distinct  both  from  the  cartilage  above 
and  the  fleshy  part  of  the  lobe,  which  it  appears  to  pass  through. 


TUMORS     OF     THE    AURICLE. 


167 


The  skin  covering  it  is  smootli,  and  of  a  light  pinkish  hue,  like  that 
of  a  keloid  tumor.  It  greT7  gradually  from  the  orifice  made  for 
holding  the  ear-ring,  and  has  been  several  months  attaining  its  present 
size.  The  tumor  upon  the  opposite 
side,  which  also  surrounds  the  hole  made 
for  the  ear-ring,  is  much  paler  in  color 
and  not  larger  than  a  garden  pea.  The 
girl  states,  that  she  experienced  a  great 
deal  of  pain  and  soreness  in  the  wounds 
made  in  piercing  her  ears,  and  that 
about  three  or  four  months  afterwards 
she  was  obliged  to  remove  the  ear-rings 
on  account  of  the  irritation  they  pro- 
duced. The  large  tumor  was  dissected 
out,  and  the  elliptical  aperture  left  in 
the  lobe  brought  together  with  sutures. 
It  healed  kindly,  and  the  disease  did  not 
return.  This  second  cut  shows  the 
shape  of  the  tumor  in  profile.  A  sec- 
tion of  the  tumor  exhibited  a  dense  yellowish-white  fibrous  appear- 
ance, and  was  so  hard  that  the  nail  made  little  ^.   ,, 

.  .  .  .  Fig.  12. 

impression  upon  it.  I  saw  this  patient  about 
six  months  afterwards,  and  as  the  excrescence  in 
the  lobe  on  the  right  side  had  not  increased,  she 
was  unwilling  to  have  it  interfered  with.  Mr. 
Williams,  in  his  Treatise  on  the  Ear,  relates  a 
case  of  tumor  of  the  lobe  which'  was  removed 
by  Professor  Syme,  and  which,  from  the  descrip- 
tion, would  appear  to  be  very  similar  to  that 
which  I  have  described. 

If  tumors  of  this  description  were  frequently  to  follow  the  irrita- 
tion caused  by  piercing  the  ears,  we  should  find  them  much  more 
common,  particularly  among  those  nations  who  wear  very  large, 
heavy,  pendulous  ornaments  there ;  but  I  have  frequently  seen  the 
hole  made  to  hold  the  ear-ring  elongated  to  a  slit  three-quarters  of  an 
inch  long  in  some  of  the  African  and  Oriental  tribes.  The  South 
Sea  Islanders  introduce  pieces  of  wood,  shells,  and  other  large  sub- 
stances, into  apertiu'es  made  in  the  lobes. 

In  a  case  of  goitre,  where  the  tumor  extended  over  the  side  of 
the  neck,  along  the  course  of  the  mastoid  muscle,  which  I  remember 


168 


INFLAMMATIONS     OF     THE    AURICLE. 


seeing  in  the  west  of  Ireland  some  years  ago,  the  lower  portion  of 
the  auricle  was  enlarged  to  the  size  of  the  palm  of  the  hand ;  and  we 
read  that  pendulous  tumors,  growing  from  the  external  ear,  are  not 
unfrequent  in  those  parts  of  India  where  goitre  prevails.  Dr.  Graves 
has  published  a  case  of  fatty  deposit  in  the  lobes ; — the  patient  died 
subsequently,  and  Dr.  O'Ferrall  found,  upon  dissection,  a  fatty  de- 
generation of  the  liver,  and  fatty  deposits  in  other  portions  of  the 
body. 

J.  E.,  a  male,  aged  24  (No  18  in  Registry).  A  tumor  about  the 
size  of  a  small  pear,  occupies  the  upper  portion  of  the  left  auricle, 
between  the  helix  and  the  concha.  It  is  immovable;  has  a  tense, 
elastic  feel,  like  that  of  a  hydrocele,  and  the  skin  covering  it  is 
smooth,  and  of  a  dusky  red  color.  The  whole  auricle  is  very  hot, 
but  the  pain  is  not  great.  It  is  of  three  months'  duration,  and  has 
been  several  times  lanced  by  a  medical  man,  and  a  quantity  of  glairy 
matter  discharged;  but  as  soon  as  the  wound  healed  the  fluid  reaccu- 
mulated.  Hearing  unimpaired.  The  case  when  admitted  presented 
the  characters  shown  in  the  accompanying  illustration. 

Kg.  13.  A  free  incision  was  made  through 

^"~  ■'      entire  length   of  the  tumor,  and 

•ut  two  ounces  of  glairy  tenacious 
d,  of  a  yellow  color,  like  that  con- 
led  in  a  ranula  or  an  enlarged  bursa, 
mixed  with  portions  of  flocculent 
fcter,  was  discharged.  The  sac  was 
I  nd  to  be  smooth  and  polished.  The 
md  was  dressed  from  the  bottom, 
h  dossils  of  lint,  and  a  cold  lotion 
5  applied  to  the  auricle.  Under 
i  plan  of  treatment  the  fluid  did 
again  accumulate,  but  the  auricle 
i^±oSented  a  hard,  thickened,  nodulated 
feel  and  appearance,  which  remained 
for  months,  and  completely  efiaced  the 
natural  curvatures  and  sinuosities  of 
that  portion  of  the  external  ear.  While  the  patient  remained  in  at- 
tendance at  the  Institution,  he  took  Plummer's  pill  and  bark,  and  had 
the  thickened  auricle  painted  over  with  tincture  of  iodine  every  third 
day. 

This  is  a  rare  form  of  disease  in  man,  but  I  have  frequently  seen 


1 


INFLAMMATIONS     OF     THE     AURICLE.  169 

it  in  dogs,  "vvhen  it  forms  a  hard  lump  attached  to  the  end  of  the  long 
flexible  auricle.  In  one  instance  that  I  remember,  it  caused  so  much 
inconvenience  to  a  valuable  pointer,  that  it  had  to  be  excised.  Mr. 
Offier  Ward  has  related  cases  of  similar  tumors  in  men  and  animals. 

a 

INFLAMATIONS  OF  THE  AURICLE 

May  occur  idiopathicallj  or  from  accident.  Simple  'phlegmon  is  not 
common  unless  induced  by  the  stings  of  wasps  or  bees,  when  the  part 
swells  to  a  great  extent,  but  it  seldom  requires  treatment.  In  idio- 
pathic inflammation  the  most  efficacious  treatment  is  puncturing 
with  a  lancet,  and  the  application  of  heat  and  moisture.  The  lobe 
occasionally  suppurates,  and  small  boils  frequently  form  upon  diffe- 
rent parts  of  it,  but  their  seat  is  chiefly  round  or  within  the  meatus, 
in  the  consideration  of  which  part  they  will  be  described,  A  Ger- 
man physician,  Dr.  E.  Bird,  has  described  a  form  of  inflammation 
peculiar  to  insane  persons,  in  which  the  auricle  swells  until,  in  some 
cases,  the  skin  breaks,  and  the  parts  discharge  thick  dark-colored 
blood  and  serum.  Having  no  experience  of  this  afiection  myself,  I 
wrote  to  a  number  of  medical  friends  connected  with  lunatic  asylums, 
and  although  their  statements  varied  both  as  to  its  existence  and 
cause,  the  establishment  of  the  disease,  as  aflecting  a  particular  class 
of  the  commu.nity  in  this  country,  has  been  fully  established.  Dr. 
Thurnham,  of  the  Wilts  Asylum,  who  has  had  so  much  experience  on 
the  subject  of  lunacy,  is  of  opinion  that  the  disease  has  frequently 
been  induced  by  injury,  and  that,  consequently,  it  was  much  more 
common  when  restraint  was  extensively  used  than  at  present. 

Acute  erysipelatous,  injiammation  frequently  attacks  the  auricle. 
It,  as  well  as  phlegmonous  inflammation,  may  occur  in  connexion 
with  general  otitis,  and  particularly  inflammation  of  the  external 
auditory  canal ;  or  it  may  be  caused  by  the  application  of  leeches,  or 
by  mechanical  injury.  Generally,  however,  it  spreads  from  the  head 
and  face,  in  which  case  a  depot  of  matter  frequently  forms  in  the 
auricle,  as  well  as  in  the  eyelid. 

Ohronic  erysipelas  is  a  frequent  form  of  disease,  particularly  among 
females  in  advanced  life,  in  this  country.  Generally  speaking,  the 
patient  has  first  an  attack  of  acute  erysipelas  of  the  head  and  face. 
The  ear,  from  being  in  such  persons  usually  tied  up  and  excluded 
from  the  air,  does  not  resume  its  natural  healthy  appearance  along 
with  the  other  parts  aff"ected,  and  the  patient  has  several  repetitions 
of  the  disease  in  the  ear  alone,  each  attack  leaving  the  auricle  more 


170 


INFLAMMATIONS     OF     THE     AURICLE. 


thickened  and  misshapen,  until  it  becomes  a  hard,  lumpy  mass,  finally 
rendering  the  meatus  a  mere  slit.  It  is  a  most  tedious  and  irritating 
disease.  The  following  case  (No.  23  in  the  Registry)  is,  with  the 
accompanying  illustration,  a  good  example  of  the  affection. 

T.  M.,  a  female,  aged  52,  has  had  frequent  attacks  of  erysipelas 
of  her  head  and  face  during  the  last  five  or  six  years.     The  effects 
Fig.  14.  of  the    disease    are,  however,  now  manifest 

only  in  the  external  ears,  but  more  particu- 
larly the  left.  The  auricle  is  not  much  en- 
larged, but  has'  become  hard,  inflexible,  and 
resembles  a  piece  of  wet,  thick  sole  leather ; 
its  fossffi  being  apparently  filled  up  by  subcu- 
taneous deposit.  It  is  also  somewhat  short- 
ened in  its  antero-posterior  diameter.  The 
skin  is  of  a  dusky  brown  color,  without  any 
exudations,  eruptions,  or  crusts  upon  it,  but 
to  the  feel  it  is  lumpy  and  nodulated,  like 
what  we  find  in  certain  forms  of  elephanti- 
asis ;  the  lobe  in  particular  presents  this 
thickened  appearance.  The  disease  has  ex- 
tended some  way  in  front  of  the  tragus, 
which  is  also  thickened  and  lumpy  :  and  the 
meatus  is  nearly  closed. 

Dr.  Kramer  relates  cases  of  "  scirrhous  degeneration"  of  the  auri- 
cle, but  it  would  appear  that  he  applied  the  term  to  afi"ections  similar 
to  that  now  under  consideration. 

The  treatment  of  acute  erysipelas  of  the  auricle  differs  in  no  way 
from  the  ordinary  rules  for  the  management  of  that  disease  else- 
where, and  that  of  the  chronic  form  just  described  is  so  similar  to  the 
treatment  of  eczema  aurium,  given  at  page  172,  that  I  refer  the 
reader  thereto. 

The  various  exanthematous  eruptions  affect  the  external  ear  as 
well  as  every  other  portion  of  the  body.  It  is,  however,  remarkable, 
that  although  the  ear  is  equally  exposed  with,  and  from  its  situation 
more  liable  to,  irritation  from  pressure  than  the  face,  that  it  is  seldom, 
even  in  the  worst  cases,  marked  with  small-pox. 

Grouty  inflammation  of  the  external  ear  has  been  fully  established. 
Dr.  Graves,  who  was  the  first  to  describe  this  affection,  says,  that  the 
state  of  congestion  of  the  auricle  seldom  lasts  long,  and  generally 
subsides  on  the  occurrence  of  the  disease  in  the  extremities. 


CUTANEOUS    AFFECTIONS     OF    THE    AURICLE.  171 

I  do  not  think  tliat  chilblains  are  now  as  common  in  this  country 
as  they  were  formerly,  and  perhaps  this  may  be  owing  to  the  manifest 
change  which  has  taken  place  in  our  winter  climate  during  the  last 
twenty  years.  In  children  and  young  persons  who  suffer  from  these 
affections,  the  auricles  are,  from  their  exposed  position,  particularly 
liable  to  be  affected.  In  cold  climates  the  external  ear  is  constantly 
frost-bitten.  During  the  severe  winter  of  1840-41  the  hospitals  of 
Vienna  presented  numerous  examples  of  frost-bitten  ears.  At  the 
same  time  scarcely  a  night  elapsed  without  a  soldier  being  frozen  to 
death  at  his  post. 

Enlarged  sebaceous  follicles  frequently  present  in  the  concha  in 
pale,  cachetic  persons  laboring  under  aural  diseases.  They  are  easily 
recognised  by  their  dark  heads,  and  can  be  pressed  out  Avith  a  pair 
of  forceps. 

CUTANEOUS  AFFECTIONS  OF  THE  AURICLE  AND  MEATUS. 

Diseases  of  the  skin  of  the  auricle  are  by  no  means  uncommon, 
and  independent  of  the  irritation  which  they  produce,  they  may,  if 
allowed  to  extend  into  the  meatus,  produce  disease  in  the  external 
layer  of  the  membrana  tympani,  and  deafness.  The  most  frequent 
forms  of  skin  disease  in  the  auricle  are  eczema  and  herpes,  but  dis- 
eases of  the  scalp  do  not  usually  affect  that  organ.  Syphilitic  ulce- 
ration is  by  no  means  uncommon,  and  rupise  are  frequently  seated  on 
the  external  ear. 

The  following  case  (No.  22  in  the  Registry)  of  eczema  aurium, 
with  thickening,  and  closure  of  the  external  meatus  as  a  consequence 
thereof,  is  highly  characteristic  : — 

M.  Q.,  a  female,  aged  60,  has  been  deaf,  "  off  and  on,"  for  several 
years  past,  accompanied  by  noise  and  wandering  pains  in  her  head, 
with  extreme  itchiness  in  the  auditory  passages.  The  skin  covering 
the  auricle,  and  the  scalp  adjacent  thereto,  is  of  a  fiery  red  color, 
speckled  with  patches  of  yellow,  formed  by  the  exudation  which  has 
collected  in  thin  branny  scales  all  over  it.  The  parts  are  hot,  and  in 
some  places  sticky,  from  a  thin  ichorous  matter  which  exudes  from 
the  surface.  The  auricle  has  lost  its  natural  shape,  its  folds  and 
sinuosities  being  partially  obliterated,  and  it  has  become  hard,  thick- 
ened, and  lumpy.  The  external  auditory  aperture  has,  owing  to  the 
disease  extending  into  it,  been  lessened  to  a  third  of  its  natural  size, 
and  it  is  filled  with  branny  scurf.  Upon  removing  the  latter  impedi- 
ment, we  can  obtain  but  a  very  partial  view  of  the  membrana  tym- 


172  CUTANEOUS     AFFECTIONS     OF     THE     AURICLE. 

pani,  which  appears  to  be  thickened  and  opaque.  Hearing  distance? 
touching.     The  state  of  the  parts  is  nearly  the  same  on  both  sides. 

In  examining  diseases  of  the  external  meatus  and  auditory  tube  like 
this,  I  find  the  small  silver  instrument,  shaped  like  a  blunt  gorget, 
figured  at  page  66,  very  useful. 

Cases  of  this  description,  and,  like  this,  of  long  standing,  are  very 
hard  to  manage,  because  there  generally  co-exists  some  constitutional 
taint,  as  shown  in  the  cutaneous  eruptions  often  manifest  in  other 
portions  of  the  skin,  and  because  the  parts  now  under  consideration 
have  become  so  much  altered  in  form  and  texture,  that  it  requires  a 
long  course  of  treatment  to  restore  them  to  their  natural  condition, 
and  thereby  re-establish  their  usual  functions.  The  disease  princi- 
pally occurs  in  females  of  middle  and  advanced  life ;  but  it  also  hap- 
pens to  children  from  six  to  twelve  years  of  age.  In  the  latter, 
however,  it  is  of  much  more  active  nature,  at  the  same  time  that  it  is 
much  more  amenable  to  treatment.  In  young  persons  the  eruption 
often  co-exists  with  scald  head,  and  in  both  young  and  old,  if  the 
disease  is  allowed  to  exist  for  any  length  of  time,  it  extends  into  the 
meatus,  and  even  over  the  surface  of  the  tympanal  membrane,  which 
it  thickens  and  renders  opaque.  In  old  persons  a  collection  of  branny 
scales  accumulates  in  the  external  tube ;  and  in  young  persons  a  thick 
creamy  discharge  coats  over  the  lining  of  the  canal  and  the  external 
layer  of  the  membrana  tympani. 

Cleanliness  and  attention  are  indispensable  to  the  eradication  of 
these  affections.  In  the  first  instance,  continual  poulticing  with  any 
emollient  substance  which  keeps  up  heat  and  moisture  is  necessary. 
Linseed  meal,  boiled  bread  and  milk,  or  well-mashed  turnips,  will  be 
found  useful  applications.  Afterwards,  when  the  extreme  heat,  swell- 
ing, vesication,  and  redness,  have  subsided,  a  solution  of  the  liquor 
plumbi,  in  the  proportion  of  a  drachm  to  the  ounce,  applied  with  seve- 
ral bits  of  fine  lint,  so  as  completely  to  envelope  the  auricle,  and  the 
evaporation  prevented  by  covering  over  the  whole  with  a  piece  of 
oiled  silk,  rarely  fails  to  lessen  the  irritation,  and  reduce  the  parts  to 
a  healthy  condition.  The  solution  of  gutta  percha  in  chloroform, 
lately  introduced  by  Dr.  Graves  in  the  treatment  of  other  skin  dis- 
eases, I  have  found  a  very  admirable  remedy  in  the  chronic  form  of 
eczema  aurium.  The  part  should  be  painted  over  several  times,  until 
a  complete  varnish  has  been  laid  on,  when  the  greatest  relief  from  the 
heat  and  itching  is  experienced.  The  application  should  be  repeated 
from  day  to  day,  as  the  material  soon  begins  to  peel  off,  but  should 


CUTANEOUS     AFFECTIONS     OF    THE    AURICLE.  173 

never  be  applied  until  the  acute  attack  has  subsided.  When  the 
auricle  is  shining,  of  a  bright  red,  and  swollen,  punctures  made  with 
the  point  of  a  lancet,  particularly  in  the  helix,  will  give  great  relief. 
In  the  chronic  stage  good  may  be  effected  by  painting  the  part  with 
a  strong  solution  of  nitrate  of  silver. 

But  while  we  employ  these  local  measures,  we  must  not  neglect 
constitutional  means.  Strict  attention  to  diet  should  be  enforced; 
salt  meats,  savoury  dishes,  and  pastry,  ought  to  be  avoided,  and  a 
sufficient  quantity  of  fresh  vegetables  should  be  consumed  at  dinner. 
After  the  patient  has  been  well  purged,  a  course  of  Plummer's  pills 
may  be  prescribed  with  advantage — at  least,  five  grains  daily  for  an 
adult ;  and,  in  a  little  time,  some  of  the  preparations  of  sarsaparilla 
administered  in  lime  water  will  hasten  the  cure,  and  assist  to  eradi- 
cate the  disease  from  the  system.  This  affection  is  very  apt  to  re- 
lapse, and  we  should,  therefore,  continue  both  our  local  and  constitu- 
tional remedies  long  after  the  inflammatory  symptoms  have  subsided. 
Old  ladies  think  they  never  can  have  a  sufficient  amount  of  warmth 
about  the  head,  and  it  is  very  difficult  to  induce  them  to  leave  off 
even  one  flannel  nightcap ;  but  we  should  at  least  make  the  attempt, 
as  the  head  and  ear  ought  to  be  kept  as  cool  as  possible.  As  the 
swelling  and  inflammatory  symptoms  subside,  we  should  again  turn 
our  attention  to  the  state  of  the  auditory  tube.  If  any  discharge 
exists,  the  meatus  should  be  syringed  gently  with  tepid  water  daily ; 
and  both  it,  the  concha,  and  the  tympanal  membrane,  washed  over 
every  second  or  third  day  with  a  solution  of  nitrate  of  silver  of  the 
strength  of  at  least  twelve  grains  to  the  ounce.  Still  more  advanced 
in  the  progress  of  the  treatment,  when  the  exudation  has  completely 
ceased,  and  the  thickened  cuticle  has  been  quite  removed,  much  bene- 
fit will  be  derived  from  smearing  over  the  tube  and  membrana  tym- 
pani  with  brown  citrine  ointment  [Ungt.  Citrinum  Fuscum)  every 
third  or  fourth  day.  It  should  be  applied  in  a  melted  state  with  a 
camel's-hair  pencil,  and  diluted  by  about  one-third  of  almond  oil. 
This  ointment,  in  which  I  have  great  faith  in  all  diseases  similar  to 
that  now  under  consideration,  should  be  made  with  either  rape-oil  or 
cod-liver  oil,  instead  of  the  olive  oil  with  the  lard  or  butter  usually 
directed  in  the  Pharmacopoeias ;  it  is  then  of  a  much  darker  color, 
and  never  becomes  hard  or  crumbly.* 

*  There  is  no  other  medicine  in  the  whole  Materia  Medica  so  frequently  prescribed 
by  the  practitioner  which  presents  the  same  differences,  both  in  appearance  and  effects, 
as  the  ointment  of  the  nitrate  of  mercury.     Prepared  as  directed  in   any  of  the  Phar- 


174  CUTANEOUS    AFFECTIONS     OF     THE     AURICLE. 

Besides  those  eczematous  eruptions,  many  other  cutaneous  diseases 
affect  the  auricles,  particularly  in  children.  Excoriations  take  place 
in  infants  behind  the  ears  during  dentition.  There  is  a  popular  be- 
lief that  they  are  salutary.  Cleanliness  is  their  chief  cure  "when  it  is 
advisable  to  heal  them  up. 

We  have  a  disease  in  Ireland — so  prevalent  in  some  counties  that 
it  would  appear  to  be  one  of  our  national  maladies — Pemphigus  Gfan- 
grenosis,  first  described  by  the  late  Dr.  Whitley  Stokes,  and  of  which 
I  have  given  a  description  in  the  medical  memoir  attached  to  the  Cen- 
sus of  1841.  So  fatal  is  this  disease  among  children,  that  no  less 
than  17,799  deaths  have  been  attributed  to  it  in  ten  years ;  and  as  it 
is  a  disease  very  well  known  to  the  lower  orders,  I  am  inclined  to 
think  that  the  amount  has  not  been  exaggerated.  It  goes  under  diffe- 
rent local  names,  but  the  most  common  are  "mortifying  hive," 
"burnt  hole,"  and  "black  ear;"  the  latter  from  its  so  frequently 
appearing  behind  the  ears  and  under  the  auricles.  In  the  Irish  it  is 
styled  Itheheadh,  or  the  eating  disorder,  from  its  phagedenic  charac- 

macopcEias  of  the  three  kingdoms,  it  is  impossible  to  procure  it  ahke  in  any  four  diffe- 
rent establisliments.  It  is  found  of  all  shades  of  color, — straw-colored,  gray,  green,  yel- 
low, orange,  and  of  every  degree  of  consistence,  dry  and  hard,  or  soft  and  pasty.  If 
mixed  with  almond  oil,  as  in  diluting  it  into  an  eye-salve,  it  soon  becomes  green,  and 
gets  a  very  unpleasant  smell,  whether  covered  up  or  not ;  and  in  this  state  it  is  often 
very  irritating.  Many  apothecaries  in  Dublin  do  not  adhere  to  the  pharmacopoiial 
formula,  but  make  it  up  according  to  a  form  of  their  own  ;  some  use  fresh  butter  instead 
of  lard ;  and  others,  different  kinds  of  oil,  as  from  habit  or  experience  they  find  best. 
On  explaining  my  difficulties,  some  years  ago,  to  Mr.  Donovan,  he  procured  me  a  citrine 
ointment  of  a  very  dark  orange  or  brown  color,  soft,  perfectly  and  equally  smooth,  and 
which  does  not  alter  in  any  way  by  keeping,  by  exposure  to  light,  by  mixing  ■with  oils 
or  even  by  being  gently  heated  to  the  point  of  fluidity;  and  it  never  acquires  an  acid 
smell.  Its  therapeutic  effects  I  have  had  long  experience  of,  and  they  are  decidedly 
superior  to  those  of  the  ointment  in  common  use.  Mr.  Donovan  has  not  made  known 
its  constituents,  nor  its  mode  of  preparation.  Mr.  Nicholls  has  made  for  me  a  citrine 
ointment  precisely  similar  in  color,  smell,  consistence,  and  effects,  and  he  informs  me 
that  he  uses  rape  oil  instead  of  olive  oil,  and  does  not  let  the  heat  employed  during  the 
preparation  exceed  200°.  Mr.  John  Evans  has  employed  cod-liver  oil,  and  also  seal  oil, 
and  the  preparations  thus  produced  are  exceedingly  elegant  and  useful  ones.  Mr.  Car- 
roll likewise  uses  cod-liver  oil  in  the  composition  of  this  unguent.  Messrs.  Bowley  have 
obtained  for  me  a  brown  citrine  ointment,  somewhat  like  those  already  mentioned,  and 
they  inform  me  that  it  is  by  using  only  the  very  purest  olive  oil.  I  find  this  ointment  a 
decided  improvement  on  the  old  preparation,  and  its  composition  should  be  investigated 
by  those  engaged  in  the  preparation  of  medicines  and  pharmacopoeias.  When  about 
to  be  used,  it  should  be  melted  to  the  consistence  of  cream  by  placing  the  vessel  con- 
taining it  in  hot  water.  It  forms  an  admirable  application  in  ophthalmia  tarsi,  as  well 
as  in  various  diseases  of  the  ear. 


POST- AURAL     TUMORS.  175 

ter.  The  vesicles,  or  bullae,  peculiar  to  this  affection,  generally  leave 
an  indelible  and  irregular  lace-like  depression,  similar  to  that  of  vac- 
cination. 

Idipoid  and  other  iiiihealthy  ulcerations  may  either  commence  in  the 
auricle  or  spread  to  it  from  the  neighboring  parts.  I  am  acquainted 
with,  and  possess  a  drawing  of,  a  case  of  cutaneous  cancerous  ulceration, 
extending  from  beneath  the  zygoma,  which  has  eaten  away  the  tragus, 
and  completely  occluded  the  external  meatus.  It  remained  nearly 
stationary  for  many  years ;  sometimes  it  spread  over  the  cheek,  and 
at  other  times  engaged  a  considerable  portion  of  the  auricle.  Its 
progress  has  usually  been  arrested  by  the  application  of  chloride  of 
zinc.  In  character  and  appearance,  as  well  as  the  peculiarity  of  the 
cicatrix  which  it  leaves,  it  greatly  resembles  that  form  of  cutaneous 
cancer  affecting  the  eyelid  described  by  Dr.  Jacob.  Excessively  irri- 
table sores,  with  hard  elevated  edges,  frequently  form  on  the  external 
margin  of  the  helix,  but  true  cancer  of  the  auricle  is  very  rare.  Mr. 
Travers,  of  London,  has  recorded  a  well-marked  example,  in  which 
he  removed  the  disease.  The  auricle  remained  unaffected  to  the  last 
in  those  cases  of  malignant  fungus  of  the  ear  which  I  have  seen. 

DISEASES    OF   THE    MASTOID   AND    PEE-AURICULAR   REGIONS. 

As  I  have  already  remarked  at  page  66,  the  state  of  the  mastoid 
region  demands  our  most  serious  consideration. 

Tumors  behind  the  ear,  and  in  any  way  connected  with  the  mas- 
toid process,  require  the  immediate  and  special  attention  of  the  prac- 
titioner. Without  entering  too  minutely  into  the  subject  here,  I  may 
specify  six  kinds  of  post-aural  tumors  with  which  I  am  familiar,  and 
the  situation  and  characters  of  which  every  surgeon  should  be  ac- 
quainted with,  as  some  of  them  may  prove  fatal  in  either  the  acute  or 
chronic  form. 

There  is  a  small  gland  lying  upon  the  mastoid  process  immediately 
above  the  insertion  of  the  sterno-mastoid  muscle,  and  on  a  level  with 
the  tube  of  the  ear,  which  sometimes  enlarges  to  the  size  of  an  al- 
mond :  it  becomes  highly  irritable  and  painful  to  the  touch,  so  as 
occasionally  to  resemble  a  nem'oma.  It  generally  occurs  in  young 
females.  I  remember  one  such  case  which  I  attended  some  years  ago, 
and  it  was  so  painful  that  the  lady  could  not  bear  to  have  it  touched. 
The  external    application  of  iodine,  and  the   internal  exhibition  of 


176  POST-AURAL     TUMOES. 

tonics,  particularly  iron,  will  in  time  remove  these  tumors,  but  the 
cure  is  always  very  tedious. 

The  second  form  of  tumor  is  also  glandular,  and  of  this  I  have 
given  an  example  on  the  next  page.  It  is  simply  a  suppurating 
gland,  and  is  not  unfrequently  met  with  in  young  children  during 
dentition.  •  It  generally  appears  in  scrofulous  constitutions,  and  very 
often  in  persons  who  have  suffered  from  some  inflammatory  action  in 
the  middle  ear  or  the  external  meatus.  Such  was  the  case  in  the  in- 
stance related  below,  as  I  learned  from  an  inspection  of  the  tympanal 
membrane,  as  well  as  from  the  loss  of  hearing.  I  never  saAV  one  of 
those  suppurating  glands,  the  great  bulk  of  which  was  not  below  the 
level  of  the  external  meatus,  and  this  is  a  diagnostic  of  some  import- 
ance, as  a  very  formidable  and  often  fatal  swelling,  which  sometimes 
occurs  behind  the  auricle,  is  always  seated  higher  up.  The  treat- 
ment for  this  form  of  tumor  is  generally  such  as  was  practised  in 
the  case  described. 

A.  H.,  aged  19  (No.  3  in  the  Registry),  a  grocer's  shopman,  re- 
siding in  one  of  the  back  streets  in  an  unhealthy  part  of  the  city 
applied  at  the  Hospital  on  account  of  a  tumor  which  existed  behind 
the  right  ear,  and  somewhat  below  the  mastoid  process.  It  was 
about  the  size  of  half  an  orange,  oval  in  shape,  hard  to  the  touch, 
and  of  a  purplish  red  hue,  altogether  very  much  resembling  the  cha- 
racter of  a  syphilitic  bubo.  It  did  not  give  the  patient  much  uneasi- 
ness, and  very  little  increase  of  pain  was  experienced  on  pressing  it ; 
he  had  not  had  any  pain  in  the  ear  or  the  side  of  the  head,  and  he 
says  he  never  had  otorrhoea.  The  tympanal  membrane  is  partially 
thickened  and  opaque ;  he  heard  the  watch  only  when  touching.  The 
left  ear  was  normal  in  function  and  appearance.  Although  he  stated 
that  he  was  in  his  usual  health,  slept  well,  and  had  his  ordinary  appe- 
tite, he  was  evidently  an  unhealthy  subject ;  his  face  was  pallid ;  his 
skin  had  a  greasy  aspect ;  the  pulse  was  small ;  and  the  tongue  large, 
white,  and  its  margin  much  indented  by  the  teeth.  He  gave  a  very 
unsatisfactory  account  of  his  disease ;  said  he  never  had  syphilis,  and 
bore  no  external  mark  of  scrofula.  What  was  the  original  cause  it 
was  difficult  to  say,  and  the  patient  appeared  to  be  totally  indifferent 
about  his  deafness.  We  sometimes  find  a  patient  remarkably  apt 
and  intelligent  in  all  the  affairs  of  life  who  can  give  but  a  very 
meagre  account  of  the  history  or  symptoms  of  any  disease  under 
which  he  may  labor,  whereas  other  persons  seem  to  be  endowed 
with  a  special  and  often  morbid  taste  for  medical  details,  so  much  so 


POST-AURAL    TUMORS.  177 

that  they  sometimes  neglect  their  ordinary  worldly  concerns  that  they 
may  be  able  to  talk  over  their  complaints  with  any  one  who  will  listen 
to  them.  The  patient  was  directed  to  foment  and  poultice  the  tu- 
mor ;  to  avoid  exposure  to  cold,  and  to  take  some  aperient  medicine. 

This  man  did  not  return  to  the  hospital  until  eight  days  had  elapsed, 
as  he  said  the  lump  gave  him  little  or  no  inconvenience,  and  had 
opened  two  days  ago.  It  then  more  than  ever  presented  the  charac- 
ters belonging  to  a  sujDpurating  gland  in  the  inguinal  region.  There 
was  a  large  irregular  opening,  sufficient  to  admit  the  top  of  the  fore- 
finger ;  its  edge  was  flabby,  inverted,  and  of  a  deep  purple  hue.  The 
interior  of  the  cavity  was  smooth;  polished,  and  of  a  dark  red  color, 
totally  devoid  of  granulations,  and  discharging  a  thin  ichorous  matter. 
He  had  no  headache,  did  not  sweat  at  night,  but  thought  his  strength 
and  appetite  were  not  so  good  as  usual.  Simple  dressing  was 
appKed  to  the  sore,  a  tablespoonful  of  bark  mixture  was  ordered  to 
be  taken  thi'ee  times  a  day,  and  the  patient  was  recommended  to  re- 
move some  distance  into  the  country.  Under  this  treatment  the  man 
recovered  perfectly  in  a  fortnight. 

The  third  form  of  tumor  I  have  only  seen  upon  two  occasions ;  it 
is  a  chvonic  abscess,  very  similar  to  lumbar  abscess,  and  is,  like  it,  I 
believe,  generally  connected  with  diseased  bone.  I  remember  a  little 
boy  at  the  hospital,  about  five  years  ago,  who  labored  under  this  dis- 
ease upon  both  sides,  and  of  which  I  possess  a  drawing.  Each  tu- 
mor was  about  the  size  of  half  a  hen-egg,  fluctuating,  painless,  and 
occupying  all  the  bare  space  behind  the  auricle ;  the  skin  nearly  of 
the  natui-al  color,  but  traversed  by  several  blue  veins.  I  opened 
these  tumors,  from'  each  of  which  poured  a  quantity  of  the  usual 
scrofulous  curdy  matter.  Almost  the  entire  of  the  surface  of  each 
mastoid  process  was  denuded  and  rough.  The  abscesses  filled  several 
times ;  the  child's  health  gave  way ;  hectic  ensued,  and,  missing  it 
for  some  time  from  the  Institution,  I  made  inquiry,  and  was  told  by 
the  mother  that  it  had  •'  died  of  convulsions  caused  by  water  on  the 
brain." 

The  fourth  form  of  tumor  is  the  result  of  acute  inflammation, 
either  arising  from  periostitis  of  the  mastoid  process,  and  often  ex- 
tending over  the  entire  parietal  region ;  or  caused  by  accumulations 
of  matter  in  connexion  with  the  mastoid  cells,  the  result  of  disease 
spreading  from  the  middle  ear ;  or  it  may  arise  from  chronic  inflam- 
mation and  otorrhoea  producing  caries.  With  this  external  manifes- 
tation we  sometimes  meet  with  diseased  action  of  a  sudden  and  fatal 

12 


178  POST-AURAL    TUMORS. 

nature  going  forward  in  the  inner  table  of  the  skull,  or  within  the 
cranium,  in  the  membranes  of  the  brain,  and  even  the  brain  itself. 
This  form  of  tumor  should  always  demand  our  special  attention,  and 
the  sooner  we  make  a  free  incision  in  such  cases,  not  merely  of  the 
integuments,  but  through  the  periosteum  down  to  the  bone,  the  better. 
Caries  of  the  mastoid  process  is  by  no  means  uncommon,  but  its  con- 
sideration properly  belongs  to  the  description  of  otorrhoea. 

The  fifth  form  of  tumor  is  a  true  aneurism  of  the  posterior  aural 
artery,  of  which  there  is  at  present  a  case  in  Stevens's  Hospital, 
under  the  care  of  Mr.  Colles,  who  has  kindly  permitted  me  to  make 
use  of  it. 

A.  F.,  a  female,  aged  27,  states  that  four  or  five  years  ago  she 
perceived  a  buzzing  noise  in  her  right  ear,  attended  with  an  occasional 
throbbing  sensation,  particularly  on  laying  her  head  down ;  that  sub- 
sequently she  applied  for  advice,  and  was  syringed  severely,  but  did 
not  receive  benefit.  About  eighteen  months  ago,  she  perceived  a 
small,  slightly  pulsating  tumor  behind  the  auricle,  and  having  been 
informed  of  the  dangerous  nature  of  it,  she  lately  came  up  from  the 
country  to  have  an  operation  performed.  The  auricle  is  normal.  On 
the  mastoid  region,  occupying  the  angle  formed  between  the  bone 
and  the  back  of  the  auricle,  there  is  a  pulsating  tumor  the  size  of 
an  almond  shell.  It  does  not  convey  to  the  fingers  the  usual  aneu- 
rismal  thrill,  but  upon  the  stethoscope  being  applied  to  it,  a  well- 
marked  bruit  de  soufflet  is  heard.  Its  external  covering  is  very  thin, 
but  natural  in  color.  On  compressing  the  artery  with  the  point  of 
the  finger,  near  its  source  behind  the  lobe,  the  tumor  is  immediately 
lessened  in  size,  and  becomes  flaccid,  but  resumes  its  bulk  on  remov- 
ing the  pressure.  When  the  sac  is  emptied,  the  bone  beneath  feels 
rough.     The  membrana  tympani  is  normal. 

An  endeavor  has  been  made  to  apply  pressure  by  means  of  a  pad? 
but  owing  to  the  curve  of  the  mastoid  process,  where  the  posterior 
auris  artery  is  given  off  from  the  occipital,  and  the  way  in  which  it 
lies  into  the  angle  formed  between  the  auricle  and  the  bone,  the  pres- 
sure has  not  been  efi'ectual.     Mr.  Colles  purposes  tying  the  artery. 

The  sixth  tumor  which  occurs  in  this  region  is  a  malignant  fungus, 
of  which  I  have  seen  three  cases :  one  in  a  boy  aged  10,  the  others 
in  adults  who  had  passed  50. 

Abscesses  often  form  in  front  of  the  tragus,  and  glandular  swellings 
of  the  side  of  the  neck  sometimes  encroach  upon  the  meatus,  and 
impair  hearing.     When  the  fascia  covering  the  parotid,  or  that  gland 


INJURIES    OF    THE    MEATUS.  179 

itself,  inflames,  there  is  generally  severe  pain,  throbbing,  and  tinnitus 
in  the  ear,  increased  by  the  emotions  of  the  temporo-maxillary  articu- 
lation. The  anatomical  relations  of  the  parts,  and  the  close  approxi- 
mation of  the  parotid  gland  to  the  lower  and  anterior  portion  of  the 
external  meatus,  accounts  for  the  amount  of  aural  pain  felt  in  these 
affections,  and  also  in  that  denominated  mumps. 

WOUNDS    OF    THE    EXTERNAL    MEATUS    AND    AUDITORY    CANAL. 

These  injuries  are  rare;  they  are  generally  produced  either  by 
sharp  penetrating  instruments  puncturing  or  lacerating  the  walls  of 
the  passage,  by  extraneous  bodies  forcibly  impacted  therein,  or  by 
the  injudicious  efforts  of  surgeons  to  remove  them.  I  have  frequently 
seen  the  lining  of  the  meatus  lacerated,  bleeding  freely,  and  subse- 
quently sloughing  from  rude  efforts  made  to  explore  the  canal.  After 
the  abstraction  of  the  irritating  substance,  the  treatment  of  such 
injuries  simply  consists  in  subduing  inflammation,  and  allowing  the 
punctured  or  abraded  parts  to  recover  with  the  least  possible  degree 
of  irritation.  As  in  punctured  wounds  of  the  orbit,  so  in  injuries 
penetrating  the  external  meatus,  or  the  cavity  of  the  tympanum,  a 
guarded  prognosis  should  be  given ;  as  we  knoAV  not  when  or  where 
cerebral  symptoms  will  arise  which  may  endanger  life. 

Hemorrhage  from  the  external  meatus  may  occur  from  a  variety 
of  causes,  which,  in  a  medico-legal  point  of  view,  it  is  of  considerable 
importance  carefully  to  investigate  and  fully  to  understand.  For  in- 
stance, a  dead  body  is  found ;  there  is  hemorrhage  from  one  or  both 
ears ;  and  medical  evidence  is  required  with  respect  to  the  cause  of 
death.  Now,  hemorrhage  from  the  external  ear  may  arise  from 
strangulation,  drowning,  (?)  concussion,  fracture  through  the  base  of 
the  skull,  asphyxia  produced  by  different  causes,  apoplexy,  and  other 
congested  states  of  the  circulation,  as  well  as  falls  and  blows  upon 
the  side  of  the  head ;  but,  although  this  symptom  is  thus  enumerated 
among  the  post  mortem  appearances,  the  precise  cause  of  the  hemor- 
rhage, and  the  locality  and  amount  of  lesion,  have  never  been  fully 
detailed.  Bleeding  from  the  external  ear  may  occur  in  the  progress 
of  disease,  from  slight  accident,  or  from  the  presence  of  polypus,  or 
fungoid  granulations  in  the  meatus,  and  the  amount  of  hemorrhage 
is  not  in  proportion  to  the  extent  of  injury  inflicted.  In  the  same 
way,  that  peculiar  "welling  up"  of  serum — a  well-known  character- 
istic of  fracture  of  the  base  of  the  skull,  passing  through  the  petrous 


180  FOREIGN    BODIES    IN    THE    MEATUS. 

portion  of  the  temporal  bone — has  yet  to  be  fully  explained.  As  the 
ear  is  a  part  through  which  fatal  injuries  might  be  inflicted  without 
attracting  the  attention  of  a  superficial  observer  after  death,  I  do  not 
think  the  subject  of  the  post  mortem  appearance  of  the  ear  has 
been  sufficiently  investigated  by  medico-legal  jurists. 

■    FOREIGN   BODIES   IN   THE   AUDITORY   CANAL. 

Foreign  bodies  sometimes  get  into  the  meatus  by  accident,  and  are 
oftentimes,  particularly  among  children,  introduced  by  design.  The 
amount  of  pain  and  irritation  which  they  cause  is  exceedingly  various. 
I  remember  being  out  shooting  on  a  plantation  many  years  ago  with 
a  friend,  who,  suddenly  exclaiming,  "Oh  !  an  earwig,"  and  throwing 
aside  his  gun,  fell  on  the  ground,  making  the  most  piteous  moans, 
and  rolling  about  in  convulsive  agony.  Finding  that  some  small  in- 
sect had  got  into  his  ear,  I  procured  some  water  from  a  neighboring 
ditch  and  poured  it  into  the  meatus ;  and,  as  I  watched  for  the  result, 
a  little  animal,  well  known  among  anglers  as  the  hawthorn  fly,  crept 
out,  and  the  gentleman  was  immediately  relieved.  The  fright  expe- 
rienced by  the  buzzing  of  an  insect  in  the  meatus,  as  well  as  the  pain 
and  irritation  which  it  causes,  can  only  be  appreciated  by  those  who 
have  experienced  that  unpleasantness.  The  little  animal  denominated 
the  earwig  [Forficula  auricularis)  is  said  to  have  a  peculiar  liking  for 
entering  the  external  meatus,  and  the  Dhor,  or  Dhor-de^l  {Groerius 
olens),  is  believed  by  the  lower  order  of  Irish  to  be  fatal  if  it  enters 
any  of  the  apertures  of  the  body ;  and  many  of  the  diseases  result- 
ing from  cold,  or  afiections  of  the  nervous  system  which  follow  sleep- 
ing in  the  open  air,  are  attributed  to  this  cause.  The  larvse  of  flies 
have  been  found  in  the  external  meatus ;  and  these  maggots,  having 
been  removed,  have  in  time  turned  into  perfect  animals.  To  dislodge 
insects  where  they  cannot  be  seen  and  seized  with  an  instrument,  it  is 
recommended  to  fill  the  meatus  with  oil,  in  order  that  their  spiracula, 
by  becoming  obliterated,  and  their  respiration  thus  impeded,  they 
may  be  induced  to  creep  out.  This  is  a  very  good  popular  recom- 
mendation, but  a  little  warm  water  and  a  syringe  will  probably  prove 
a  more  efi"ectual  means  of  dislodgment.  One  of  the  latest  English 
writers  upon  aural  surgery,  having  recomrii ended  "  sweet  almond  oil" 
as  the  best  remedy  for  dislodging  insects,  reminds  me  of  a  quaint, 
and  I  rather  think  sarcastic,  passage  which  I  remember  reading  in 
one  of  Boyle's  papers,  who,  in  detailing  the  difi"erent  cures  said  to 
have  been  wrought  by  marrow  extracted  from  the  thigh  bone  of  a 


POREIGX    BODIES    IX    THE     MEATUS.  181 

man  that  was  hanged,  asks  whether  the  marrow  from  the  thigh  bone 
of  any  other  man  might  not  answer  as  well.  Many  instances  have 
been  recorded  of  death  following  the  forcible  introduction  of  foreign 
bodies,  particularly  splinters  of  wood,  into  the  meatus,  either  by  pass- 
ing through  the  tympanal  cavity  into  the  labyi*inth,  or  by  exciting 
such  inflammation  in  the  injured  structures  as,  by  extending  to  the 
brain,  induces  disease  in  that  organ.  Peas  and  other  seeds  have  been 
known  to  germinate  by  being  allowed  to  remain  in  the  meatus.  JSfo. 
167  in  the  Registry  is  the  case  of  a  boy  eight  years  of  age,  iuto 
whose  external  meatus  one  of  his  schoolfellows  thrust  a  grain  of  Iil- 
dian  .corn.  The  schoolmaster,  in  his  wisdom,  endeavored  to  remove 
it  by  attaching  a  piece  of  wax  to  the  end  of  a  stick,  and  thrusting  it 
into  the  meatus.  After  an  hour's  inefi"ectual  effort,  and  the  boy  be- 
coming almost  convulsed  with  pain,  he  was  brought  to  a  surgeon,  who 
endeavored  to  remove  the  offending  body  by  means  of  a  forceps  and 
other  instruments.  The  hemorrhage,  however,  which  ensued  was  so 
great  that  it  was  deemed  advisable  to  desist.  I  saw  the  boy  four 
days  after :  a  profuse  foetid  discharge  pom-ed  out  of  the  meatus,  on 
removing  which  the  walls  of  the  canal  were  found  to  be  lacerated  and 
in  a  sloughing  condition ;  while  at  the  bottom  of  the  passage  the 
grain  of  Indian  corn,  of  a  yellow  color,  and  with  several  breaks  and 
scratches  upon"  its  smooth  hard  skin,  caused  by  the  instruments  used 
to  detach  it,  was  visible.  The  slightest  touch  of  it  caused  the  most 
excruciating  pain.  With  a  curette  similar  to  that  with  which  I  open 
the  capsule  in  extraction  of  the  lens, — its  point  being  bent  nearly  at  a 
right  angle  to  the  shaft,  introduced  cautiously  between  the  grain  of 
corn  and  the  side  of  the  meatus,  and  then  giving  the  instrument  a 
half  turn, — I  succeeded  in  first  twisting  on  its  own  axis,  and  eventu- 
ally bringing  out,  the  grain  of  corn,  which  had,  while  in  the  ear,  in- 
creased to  one-third  more  than  its  natural  size.  Fortunately  the  rnem- 
brana  tympani,  although  highly  inflamed,  had  not  been  ruptm-ed,  and 
the  parts  soon  recovered.^ 

*  [A  much  more  ingenious  plan  than  the  schoolmaster's  was  resorted  to  by  "  an  intel- 
ligent"' machinist  in  New  England,  who  was  called  upon  to  remove  a  small  stone  from 
the  ear  of  a  child  three  years  old,  which  liad  been  there  six  or  eight  days,  and  had  pro- 
duced severe  irritation  and  inflammation.  It  occurred  to  this  person,  that  something 
might  be  fastened  to  the  stone  by  means  of  glue  or  some  other  adhesive  substance. 
After  trying  many  articles  he  selected  a  strong  solution  of  gum  shellac  in  alcohol.  A 
small  portion  of  cotton  was  tied  into  a  knot  with  a  strong  thread,  and  fastened  to  a 
piece  of  quill  a  little  more  than  an  inch  long,  by  passing  the  ends  of  the  thread  through 
the  quill.     The  cotton  was  then  charged  with  the  shellac  solution  and  introduced  against 


182  FOREIGN    BODIES    IN    THE    MEATUS. 

A  practitioner  brought  a  child  to  my  house,  who,  while  playing 
with  some  pebbles,  allowed  a  small  white  stone  to  slip  into  the  exter- 
nal meatus  six  hours  before.  She  had  not  complained  of  pain ;  but 
the  friends  became  alarmed,  and  Avere  most  anxious  to  have  the  peb- 
ble removed,  "  lest  it  might  get  into  her  brain."  He  had,  he  said, 
used  various  instruments,  but  without  success,  to  extract  or  dislodge 
the  pebble.  The  child  appeared  then  in  great  agony,  and  the  coun- 
tenance was  highly  characteristic  of  the  distress  experienced.  There 
was  considerable  hemorrhage  from  the  ear,  and  the  external  aperture 
had  already  begun  to  swell.  Upon  examination  I  found  the  meatus 
extensively  lacerated,  and  could  perceive  and  touch  a  white,  rough 
surface  on  its  anterior  wall ;  but  as  I  felt  sure  that  it  was  not  the 
offending  body,  but  the  denuded  bone,  I  recommended,  strongly 
against  the  wish  of  my  friend,  a  cessation  of  hostilities,  at  least  until 
the  hemorrhage  had  ceased.  A  leech  was  applied  to  the  margin  of 
the  meatus,  and  afterwards  a  poultice  placed  over  the  ear.  Upon 
visiting  the  patient  next  morning  I  found  that  suppuration  had  been 
established  during  the  night,  and,  on  syringing  the  ear  with  a  little 
tepid  water,  the  white  quartz  pebble  presented  at  the  external  aper- 
ture, and  was  easily  removed  with  a  forceps.  Upon  further  examina- 
tion, I  found  that  the  membrana  tympani  had  been  ruptured  anteriorly, 
and  that  the  bone  was  denuded  for  a  considerable  extent  by  the  efforts 
made  to  extract  the  foreign  body.  The  parts,  however,  eventually 
resumed  their  natural  appearance.-^ 

the  stone,  where  it  was  allowed  to  remain  more  than  twenty-four  hours :  the  evapora- 
tion was  hastened  by  artificial  heat.  The  plan  was  successful  and  "  occasioned  scarcely 
any  pain,  though  considerable  force  was  required  to  remove  the  body." — Boston  Med. 
and  Surg.  Journal,  vol.  x.  p.  317  (for  1834).— A.  H.] 

'[A  similar  case  to  the  above  is  recorded  in  the  "  Journal  de  Therapeutique  "  for 
1833,  as  having  occurred  in  the  pj-actice  of  Baron  Dupuytren.  The  plan  resorted  to  for 
removing  the  foreign  body  was  certainly  a  novel  one.  The  subject  was  a  child  seven 
years  old,  who  had,  a  month  previous,  got  a  cherry-stone  in  its  external  meatus.  All 
efforts  to  dislodge  it  by  forceps,  &c.,  having  failed,  "  a  metallic  drill  was  ordered  of 
Charriere,"  which  when  completed  was  introduced  to  the  stone.  "  The  head  of  the 
child  having  been  inclined  towards  the  opposite  ear,  and  placed  on  a  table  where  seve- 
ral assistants  retained  it  firmly."  After  a  few  turns  of  the  instrument,  the  stone  re- 
mained engaged  at  the  end  like  a  cork  caught  within  a  bottle,  but  it  was  impossible  to 
withdraw  it.  The  instrument  was  therefore  removed,  and  a  larger  drill  ordered,  by  the 
aid  of  which  the  stone  was  broken  into  several  fragments ;  its  extraction  was  then 
effected  partly  with  the  forceps,  and  partly  by  consecutive  inflammation.  This  operation 
was  gravely  styled  "  Intra  auricular  Uthotrity."  Of  course,  there  was  no  further  state- 
ment made  of  the  result  of  this  operation — its  influence  on  the  hearing,  or  the  condition 


INJURIES     OF    THE    MEATUS.  183 

Bits  of  slate-pencil,  glass  beads,  cherry-stones,  paper  balls,  and 
such  like  substances,  are  constantly  introduced  into  the  meatus ;  and 
it  is  remarkable  that  the  amount  of  suffering  is  no  way  commensu- 
rate with  the  size  or  character  of  the  substance  introduced.  An  inti- 
mate friend  waited  ujjon  me  late  one  evening  in  a  state  of  great 
anxiety,  accompanied  by  his  little  boy,  who,  he  said,  had  put  some 
glass  beads  into  his  ear  in  the  morning.  On  inquiring  the  reason  of 
his  not  applying  during  the  daytime,  I  was  informed  that  the  child 
had  not  suffered  the  slightest  inconvenience,  and  had  forgotten  the 
circumstance  until  bedtime,  when  he  mentioned  it  to  one  of  the 
attendants.     The  beads  were  extracted  with  facility. 

A  woman  rushed  into  the  hospital  one  morning  in  great  alarm, 
stating  that  a  pin's  head  had  got  into  her  ear,  and  that  several  per- 
sons had  tried  in  vain  to  extract  it.  On  bringing  every  portion  of 
the  meatus  into  view,  I  was  enabled  to  assure  her  that  her  fears  were 
unfounded,  when  she  went  away  perfectly  contented,  and  quite  free 
from  the  pain  she  said  she  had  previously  experienced. 

Rude  efforts  made  to  extract  foreign  bodies  from  the  ear  are  as 
likely  to  cause  mischief  as  these  bodies  themselves.  The  simplest, 
and  often  the  most  effectual,  means  of  removing  small  substances  from 
the  meatus,  is  by  syringing  the  meatus  with  plain  warm  water.  '  If 
the  offending  body  is  not  producing  much  pain  or  annoyance,  it  is 
scarcely  fair  to  the  patient  to  introduce  some  rough  instrument  into 
the  passage,  in  the  hope  of  dislodging  it,  without  the  use  of  the  spe- 
culum, and  bringing  the  foreign  substance  well  into  its  field.  The 
operator,  merely  dilating  the  external  aperture  with  a  divaricating 
speculum,  gets  a  glimpse  of  the  offending  body, — a  piece  of  slate- 
pencil,  a  small  pea,  or  a  bead, — and  passing  down  an  ordinary  dress- 
ing forceps,  the  blades  of  which  so  fill  the  aperture  that  he  must  then 
work  by  touch  and  not  by  sight,  attempts  to  seize  the  smooth,  round, 
slippery  substance,  which  is,  at  each  effort,  pressed  down  upon  the 
membrana  tympani,  thereby  not  only  eluding  his  grasp,  but  pro- 
ducing the  most  exquisite  torture. 

The  head  should  be  placed  against  some  resisting  body,  or  firmly 
supported  in  an  operating  chair,  and  the  canal  brought  fairly  within 
the  field  of  the  speculum ;  then  the  curette,  or  the  small  silver  spatula 
figured  below,  acting  either  as  a  lever  or  a  hook,  will,  if  proper  care 

of  the  membrana  tympani  immediately  after  the  operation.  This  abstract  of  the  case 
was  made  from  the  record  of  it  in  the  Boston  Medical  and  Surgical  Journal  for  1834. 
(Vol.x.  p.  227.)— A.  H.] 


184 


DISEASES    OF    THE    CERUMENOUS    GLANDS. 


be  taken,  in  almost  every  instance  dislodge  tlie  substance ;  and  if  it 
has  got  into  a  position  where  it  cannot  be  well  got  at,  syringing  will 
often  alter  it  so  as  to  present  some  point  where  it  may  be  either 
seized  with  the  forceps  without  giving  pain,  or  where  we  can  easily 
introduce  the  curette  between  it  and  the  wall  of  the  meatus,  and  so 
extract  it.     Where  we  employ  a  forceps,  that  figured  at  page  67,  or 

Fig.  15. 


the  one  represented  along  with  the  spatula  in  the  accompanying  wood- 
cut, will  be  found  useful.  The  ingenuity  and  dexterity  of  the  ope- 
rator will,  however,  suggest  the  most  feasible  mode  of  operating.^ 

When  it  is  remembered  that  death  has  frequently  followed  the 
introduction  of  a  foreign  substance  into  the  meatus ;  and  that  epilepsy 
and  many  other  distressing  symptoms  have  ensued  from  the  same 
cause  ;  and  when  every  practitioner  who  has  met  with  cases  similar  to 
those  detailed  must  have  experienced  some  of  the  difficulties  to  which 
I  have  alluded,  the  foregoing  observations  will  not  appear  too  long. 

Acids  have  been  poured  into  the  ear  either  by  accident  or  design, 
and  have  produced'  frightful  agony,  and  even  death.  How  far 
poisons  act  when  introduced  through  the  meatus  has  not  yet  been 
fully  determined ;  but  the  idea  that  they  induced  fatal  results  was 
current  in  England  in  the  days  of  Shakspeare,  and  still  prevails 
among  the  Irish  peasantry. 


DISEASES    OF   THE    CERUMENOUS   GLANDS. 

One  of  the  most  common  and  curable  forms  of  deafness  arises  from 
impaction  of  the  auditory  canal  with  hardened  wax.  In  cases  of 
recent  accumulation,  the  dark,  shining,  convex  end  of  the  plug  may 
be  at  once  perceived  on  inspecting  the  meatus ;  in  those  of  long  stand- 
ing, where  the  fluid  portion  has  been  evaporated,  the  offending  mate- 
rial, mixed  with  hairs  and  scales  of  cuticle,  has  generally  a  concave 
surface,  is  not  polished,  and  is  seldom  so  dark  as  in  the  former  case. 
At  times  the  scale  of  hard  wax  is  not  thicker  than  a  half-crown  piece, 

'  These  instruments  are  represented  three-fourths  the  natural  size. 


DISEASES     OF    THE    CERUMENOUS    GLANDS.  185 

and  adheres  firmly  to  tlie  outer  surface  of  the  memhrana  tympani, 
causing  impairment  of  hearing  and  most  distressing  tinnitus. 

Cases  of  deafness  proceeding  from  accumulation  of  cerumen  are  so 
numerous  and  so  easy  of  cure  that  it  seems  unnecessary  to  occupy 
space  in  describing  them,  while  so  many  other  diseases  of  the  ear 
present  themselves  more  worthy  of  our  attention,  because  less  known 
and  more  difficult  to  treat.  Yet  let  me  say  that  the  ability  of  making 
a  diagnosis  in  such  cases  is  not  always  possessed  even  by  good  siu-geons 
and  physicians.  From  week  to  week  I  meet  with  cases  of  deafness 
attended  with  tinnitus  aurium,  which  have  been  ascribed  to  and  treated 
as  depending  upon  functional  or  organic  derangements  of  other  organs, 
the  stomach  and  the  brain  in  particular,  and  for  which  constitutional 
means  as  well  as  topical  applications  had  been  employed  at  conside-. 
rable  length,  but  which,  upon  examination,  proved  to  be  nothing  more 
than  firmly  adhering  pieces  of  hardened  wax. 

A  medical  friend  in  the  country  wrote  to  me  to  say  he  had  become 
suddenly  deaf  in  one  ear ;  that  he  applied  to  a  neighboring  surgeon 
who  syringed  him  "for  a  long  time  ;"  that  only  a  little  wax  came  out; 
whereon  he  had  taken  aperient  medicine,  filled  the  meatus  with  cotton 
steeped  in  brandy,  and  applied  a  blister  over  the  mastoid  process. 
As  I  could  not  possibly  advise  him  what  to  do  without  knowing  what 
was  the  cause  of  his  deafness,  or,  at  least,  having,  by  means  of  ocular 
inspection,  a  certain  amount  of  positive  and  negative  symptoms  to 
judge  from,  he  came  to  town,  when  I  found  a  layer  of  hard  dark  wax 
pasted  over  the  membrana  tympani,  which  was  easily  lifted  off  with 
a  spatula,  but  which  no  syringing  would  have  removed.  All  his 
symptoms  immediately  disappeared. 

If  we  examine  the  membrana  tympani  after  the  offending  substance 
has  been  removed,  we  will  in  most  cases  find  it  vascular,  and  the  lining 
of  the  canal  pinkish.  To  judge,  however,  from  this  state  would  be 
most  erroneous,  as  the  irritation  produced  by  the  removal  of  the  wax 
necessarily  gives  rise  to  the  vascular  condition  alluded  to.  Persons 
who  perspire  much  about  the  head  seem  to  be  more  liable  than  others 
to  collections  of  cerumen. 

Unless  illuminated  by  some  means,  natural  or  artificial,  the  external 
auditory  passage  is  a  dark  cavity,  and,  without  proper  inspection,  it  is 
not  possible  to  know,  by  any  set  of  symptoms  of  which  the  patient 
himself  is  conscious,  whether  his  disease  proceeds  from  the  simple 
mechanical  impediment  of  a  plug  of  wax,  disease  of  the  middle  ear,  or 
threatenings  of  serious  mischief  in  the  brain  itself,  because  the  two 


186  DISEASES    OF    THE    CERUMENOUS    GLANDS. 

most  prominent  symptoms,  deafness  and  tinnitus  aurium,  are  common 
to  all  three,  and  to  many  other  diseases  of  the  ear  also ;  in  the  same 
manner  as  we  find  impaired  vision  and  muscse  common  to  so  many 
diseases  of  the  eye,  as  well  as  symptomatic  of  cerebral  and  other 
affections.  I  see  few  cases  of  incipient  cataract  in  the  upper  ranks  of 
life  which  have  not  already  undergone  a  little  doctoring,  mider  the 
impression  that  the  disease  depended  upon  the  state  of  the  stomach ; 
and  blue  pills,  bitter  mixtures,  and  dietetic  regulations  have  had  full 
sway.  But,  where  so  much  has  been  achieved  for  medical  science 
during  the  last  twenty  years  by  greater  attention  to  diagnosis,  thus 
rendering  the  healing  art  a  more  accurate  science  than  heretofore,  I 
do  not  think  it  is  too  much  to  ask  the  practitioner  to  possess  himself 
of  a  small  tubular  speculum,  and  to  take  a  peep  at  the  state  of  the 
parts  he  is  prescribing  for,  before  he  resorts  to  the  routine  treatment 
alluded  to.  This  is,  properly  speaking,  one  of  the  errors  of  omission. 
Now  I  will  state  one  of  commission.  A  patient  is  seized  with  deafness 
and  a  singing  noise  in  one  of  his  ears.  The  medical  attendant,  sup- 
posing it  might  be  wax,  squirts  hot  water  with  a  poAverful  syringe  into 
the  auditory  passage  for  half  an  hour  together,  and  as  nothing  comes 
out,  he  syringes  the  harder.  All  this  time  the  patient  labored  under 
inflammation  of  the  drum  of  his  ear,  which,  I  need  not  say,  was  not 
improved  by  the  treatment  adopted.  Let  me  entreat  of  my  readers 
never  to  syringe  an  ear,  nor  to  drop  any  stimulating  application  into 
it,  until  they  have  carefully  examined  the  state  of  the  parts,  and  as- 
sured themselves  of  the  presence  of  wax  or  other  foreign  body.  My 
advice  was  sought  by  an  officer,  for  deafness  caused  by  thickening  of 
the  membrana  tymjoani.  On  asking  his  medical  attendant  what  treat- 
ment he  had  employed,  he  said,  "  I  syringed  him  every  day  for  three 
weeks,  but  nothing  came  out !" 

The  cerumenous  glands  are  more  liable  to  morbid  changes  than  the 
profession  are  aware.  The  moment  an  inflammation  is  set  up  in  the 
neighboring  structures  they  cease  to  secrete.  When  otorrhoea  is  pre- 
sent, their  function  seems  also  suspended.  At  times  they  secrete  a 
thin,  light-colored,  honey-like  cerumen,  so  quickly  and  in  such  quan- 
tity as  to  pour  out  of  the  external  meatus.  This  I  have  chiefly  seen 
in  weakly  females,  and  often  occmTing  as  a  sequel  to  some  febrile 
attack.  It  is  the  analogue  to  inflammation  of  the  Meibomian  glands. 
From  children  of  a  year  old  to  persons  of  extreme  age  we  meet  with 
collections  of  hardened  wax  in  the  ear,  and  are  called  upon  to  remove 
them ;  but  they  are  more  frequently  seen  in  middle  life  than  at  any 


DISEASES    OP    THE    CERUMENOUS    GLAXDS.  187 

period  antecedent  thereto.  They  are  not  always  accidental,  as  we 
learn  from  the  same  person  returning  again  and  again,  at  intervals  of 
two  or  three  years,  to  have  them  removed.  The  vitiated  secretion 
probably  depends  upon  some  chronic  inflammation  of  the  cerumenous 
follicles  themselves.  The  wax  is  generally  darker  in  color  than 
natural,  at  times  resembling  pitch  in  its  tenacity  and  hue.  In  other 
cases  it  becomes  as  hard  as  a  piece  of  mortar  or  concrete,  and  forms 
an  accurate  cast  of  the  meatus  auditorius  externus,  feeling  to  the  touch 
of  an  instrument  like  a  stone  or  foreign  body.  As  soon  as  this  has 
occurred,  hearing  is  much  impaired ;  but  from  time  to  time  the  patient 
feels  a  slight  report  in  his  ear,  particularly  after  eating  or  mo\ang  liis 
jaws,  and  then  the  hearing  is  much  improved  for  a  short  period.  The 
improvement  is  caused  by  the  motion  of  the  external  portion  of  the 
tube  slightly  disadjusting  the  cork  of  wax,  and  so  allowing  air  and 
sound  to  be  temporarily  transmitted  to  the  drum-head ;  but  the  im- 
provement is  lost  as  soon  as  the  plug  has  regained  its  former  position, 
or  an  additional  deposit  of  wax  fills  up  the  space,  and  again  occludes 
the  air  and  sound.  This  circumstance,  trivial  as  it  is,  is  worthy  of 
note,  because  something  very  similar  takes  place  in  another  disease 
of  the  ear,  arising  from  a  totally  different  cause.  In  catarrhal  in- 
flammation of  the  middle  ear,  with  thickening  of  the  lining  mem- 
brane, or  mucous  collections  within  the  Eustachian  tube,  or  the  cavi- 
tas  tympani,  we  perceive,  as  perhaps  many  of  us  have  ourselves 
experienced  when  laboring  under  catarrh  or  influenza,  a  sudden  re- 
port, as  if  something  gave  way  in  the  ear,  followed  by  an  immediate 
accession  of  hearing.  In  some  cases  of  complete  impaction  of  wax, 
particularly  where  it  is  very  hard  and  of  long  standing,  the  patient 
does  not  hear  the  watch,  even  when  held  to  the  auricle,  pressed 
against  the  mastoid  process,  or  laid  upon  the  forehead — symptoms 
generally  indicative  of  some  great  lesion  of  the  internal  or  middle 
ear,  or  paralysis  of  the  auditory  nerve ; — yet  as  soon  as  we  have  re- 
moved the  mechanical  impediment,  the  hearing  becomes  exalted  to  a 
degree  which  is  painful  to  the  patient  to  bear.  I  cannot  but  think 
that,  in  such  cases,  the  loss  of  power  has  arisen  from  the  pressm'e 
exercised  by  the  foreign  body  upon  the  tympanal  membrane,  and, 
through  it,  transmitted  by  the  chain  of  ossicula  to  the  labyrinth. 

Squirting  hot  water  into  the  auditory  jjassage,  even  with  the  most 
powerful  syringe,  will  not  always  succeed  in  removing  the  offending 
body.  In  fact,  if  not  properly  done,  it  rather  increases  the  impac- 
tion.    I  have,  however,  seldom  met  a  case  in  which,  with  a  little  care 


188  DISEASES    OF    THE    CERUMENOUS    GLANDS. 

and  patience,  I  could  not  remove  tlie  wax  at  one  sitting.  One  of 
tlie  cases  which  jDroved  an  exception  to  this  was  in  a  person  who  had 
a  natural  hour-glass  contraction  in  the  middle  of  the  passage,  and 
another  where  there  was  an  exostosis  the  size  of  a  split  pea  in  the 
same  locality.  The  best  syringe  to  employ  is  that  figured  at  page 
85,  worked  with  the  right  hand,  while  the  left  grasps  the  top  of  the 
helix,  and,  by  drawing  it  slightly  upwards,  outwards,  and  backwards, 
assists  to  straighten  the  meatus,  and  thus  facilitate  the  exit  of  the 
plug  of  hardened  cerumen.  The  jet  of  fluid  should  not  be  directed 
point-blank  against  the  cork  of  wax,  but  rather  to  its  edges,  where 
it  is  attached  by  a  number  of  hairs,  and  is  often  intimately  united 
with  the  cuticle.  From  time  to  time  we  should  introduce  the  spe- 
culum, and  see  what  progress  is  being  made.  The  fine  long-bladed 
forceps  may  sometimes  be  slipped  down  upon  the  offending  body,  and 
it  can  be  thus  withdrawn ;  or,  what  I  find  much  more  useful,  the  small 
silver  spatula  already  described,  and  which,  acting  as  a  lever,  moves 
the  plug,  and  so  allows  the  water  to  get  behind  it  and  force  it  out. 
Anothei;  instrument  very  useful  in  such  cases  is  a  fine  blunt  curette, 
made  of  silver,  and  with  the  end  bent  for  about  a  line  in  length  at  a 
right  angle  with  the  shaft,  referred  to  at  page  181.  By  slipping  this 
down  between  the  cork  of  hard  wax  and  the  wall  of  the  meatus,  and 
then,  when  it  has  proceeded  some  distance,  giving  it  a  half  turn,  so 
that  its  point  fixes  in  the  plug,  the  latter  may  often  be  removed  en 
masse.  Care  must,  however,  be  taken  in  using  these  little  instru- 
ments not  to  abrade  the  skin,  which  at  the  lower  portion  of  the  meatus 
is  very  delicate,  and  apt  to  bleed  upon  the  slightest  irritation.'  We 
read  in  books  on  aural  surgery,  and  in  lectures  and  details  of  cases 
given  in  periodicals,  of  various  substances  employed  for  the  purpose 
of  softiening  wax — the  last  of  which  was  glycerine ;  but,  if  attention 
is  paid  to  the  directions  I  have  now  given,  some  patience  exercised, 
and  that  we  proceed  with  care  and  delicacy,  I  do  not  think  we  need 
often  have  recourse  to  any  of  the  nostrums  recommended  for  soften- 
ing and  removing  wax.  Should  we,  however,  at  first  encounter  any 
difficulty,  or  the  patient  experiences  much  pain  from  our  manipula- 
tion, it  is  better  to  desist,  and  drop  a  little  warm  oil  into  the  ear  once 
or  twice  a  day,  or  keep  a  bit  of  cotton  moistened  with  oil  in  the  pas- 
sage, until  the  wax  had  been  partially  softened. 

'  The  ear-pan  figured  at  page  84  will  be  found  a  very  convenient,  cleanly  instrument. 
I  have  latterly  placed  the  perforated  division  across  one  end  instead  of  along  the  length 
of  the  pan. 


DISEASES    OF    THE    CERUMENOUS     GLAXDS.  189 

Simple  removal  of  the  wax  Trill  generally  restore  the  hearing  at 
the  moment,  but  the  tinnitus  often  remains  for  some  time  after.  As 
a  consequence  of  impaction  of  the  auditory  passages  with  cerumen, 
producing  thickening  of  the  cuticular  layer  of  the  membrana  tympani, 
the  two  following  cases  may  be  cited : — 

L.  W.,  a  male,  aged  40  (No.  14  in  the  Registry),  applied  on  account 
of  deafness  in  his  left  ear  of  some  weeks'  standing,  but  which  had 
recently  increased  very  much.  Complains  of  noise  like  that  of  a 
boiling  kettle.  Hearing  distance,  two  inches ;  says  it  varies  from 
time  to  time,  but  that  it  was  always  better  after  eating  until  lately. 
Occasionally  he  experiences  a  loud  noise,  as  if  a  report  took  place  in 
his  ear,  after  which  the  hearing  is  improved.  His  disease  has  been 
of  twelve  months'  standing.  Upon  examination,  I  found  the  external 
auditory  passage  filled  to  its  apertm-e  with  hard,  brownish,  inspissated 
cerumen.  It  is  so  hard,  that  percussion  with  a  probe  conveys  the 
sensation  to  the  fingers  as  if  struck  against  a  body  as  firm  and  resist- 
ing as  stone.  Numerous  short  but  firm  hairs  grow  around  the  external 
aperture,  and  some  of  the  more  internal  ones  are  probably  mixed  up 
with  the  hardened  cerumen,  and  so  assist  to  keep  it  immovably  fixed 
in  its  place.  The  mere  projection  of  a  stream  of  warm  water  from  a 
syringe  will  not  easily  remove  such  a  thoroughly  impacted  mass  as 
this.  It  must  be  assisted  out  with  the  spatula,  slightly  bent  at  the 
end,  like  the  old  lever  used  in  midwifery :  but  the  ear  should  be 
syringed  from  time  to  time  as  we  proceed  with  our  manipulations. 
When  well  loosened,  I  removed  it  en  masse  with  a  pair  of  fine  forceps, 
and  perceived  that  with  it  came  out  a  large  collection  of  hairs,  which 
had  become  entangled  within  it ;  and  that  all  its  lower  portion  and 
its  extremity  was  covered  over  with  a  layer  of  soft,  white,  thickened 
cuticle,  the  natural  lining  of  the  sm-face  with  which  it  has  been  so 
long  in  contact,  thickened  and  separated  by  the  pressure  exercised 
upon  it  by  this  foreign  body.  Immediate  relief  to  all  the  symptoms 
under  which  this  person  labored  was  experienced  by  the  removal  of 
the  foreign  substance.  The  hearing  increased  to  twelve  inches,  and 
the  noise  lessened  considerably.  Upon  inspection  through  the  specu- 
lum, the  membrana  typmpani  was  seen  whitish  and  succulent,  and 
having  the  parboiled  appearance  of  the  piece  of  cuticle  which  had 
been  removed  from  it.  Several  large  red  vessels  also  ramified  upon 
its  surface,  and  coursed  along  the  insertion  of  the  malleus  in  particu- 
lar.    This  condition  was,  no  doubt,  caused  by  the  pressui'e  of  the 


190  DISEASES    OF    THE    CERUMENOUS    GLANDS. 

accumulated  and  hardened  cerumen ;  but  in  a  few  days  the  part 
recovered  its  natural  character. 

Several  times  during  the  removal  of  this  wax  the  patient  was  seized 
with  a  fit  of  spasmodic  coughing,  apparently  caused  by  some  irritation 
in  the  larynx.  I  have  already  alluded  to  this  peculiar  phenomenon 
at  page  86.  Since  that  portion  of  this  work  was  printed,  I  met  the 
following  observations  in  the  British  and  Foreign  Medico-Chirurgical 
Re\'iew,  vol.  xvii.  p.  414 : — 

"  Pruritus  of  the  external  meatus  auditorius,  from  hypersesthesia  of 
the  auricular  branch  of  the  pneumogastric,  is  sometimes  observed, 
and  is  accompanied  by  cough  and  vomiting.  This  connexion  between 
the  ear  and  the  stomach  and  lungs  is  not  sufficiently  remembered  by 
modern  practitioners.  Arnold  mentions  an  interesting  example  of 
chronic  vomiting  in  a  child,  which  long  resisted  all  curative  means, 
but  which  was  effectually  removed  by  removing  a  bean  from  each  of 
the  child's  ears  that  had  slipped  in  while  at  jalay.  Cassius  Medicus 
has  for  one  of  his  problems, — Why  does  irritating  the  ears,  as,  for 
example,  with  a  speculum,  cause  sometimes  a  cough,  just  as  if  the 
trachea  was  irritated?" 

No.  5  in  Registry,  M.  B.,  aged  25,  a  literary  teacher,  complained 
of  general  deafness,  with  singing  noise  in  both  ears.  Upon  inspection, 
the  external  auditory  passages  Avere  found  to  be  corked  up  with  hard 
inspissated  cerumen.  This  was  removed  by  syringing  with  warm 
water  in  the  ordinary  manner,  upon  which  the  hearing  was  quite 
restored  in  the  right  and  partially  in  the  left  ear.  A  few  days 
having  been  allowed  to  elapse,  in  order  that  the  meatus  and  external 
surface  of  the  tympanal  membranes  might  regain  their  ordinary  ap- 
pearance after  the  vascularity  produced  by  the  pressure  of  the  wax, 
and  the  excitement  and  irritation  caused  by  its  removal  had  subsided, 
this  case  was  again  examined. 

Right  Ear. — Hearing  distance,  two  feet  and  a  half;  the  meatus 
dry,  but  no  appearance  of  disease  presented  upon  inspection  with  the 
speculum. 

Left  Ear. — Hearing  distance,  four  inches  ;  walls  of  meatus  covered 
with  flakes  of  thickened  whitish  cuticle,  which  presented  the  appear- 
ance of  partial  maceration,  and  nearly  filled  up  the  cavity.  Upon 
removing  these  with  a  forceps,  the  surface  beneath  presented  a  florid 
red  color.  The  membrana  tympani  was  thickened  throughout,  and 
exhibited  patches  of  vascularity,  which  deepened  into  a  continuous 
red  surface  above  and  behind  the  insertion  of  the  malleus.     He  had 


INPLAMMATIONS     OF    THE    EXTERNAL    MEATUS.      191 

a  confused  rustling  noise  in  this  ear.  The  surface  of  the  meatus  and 
the  membrana  tjmpani  was  washed  over  with  a  solution  of  nitrate  of 
silver,  five  grains  to  the  ounce ;  a  dose  of  aperient  medicine  was 
prescribed  for  him,  and  he  was  directed  to  wear  a  bit  of  cotton  wool 
in  the  external  apertm-e,  so  as  to  exclude  the  cold  air.  In  ten  days 
this  case  was  again  inspected.  The  meatus  on  the  left  side  had  re- 
sumed its  natural  color,  but  was  very  dry  and  somewhat  scaly.  The 
tympanal  membrane  had  cleared  considerably  since  last  report ;  the 
lower  portion  in  particular  had  become  quite  free  from  vascularity, 
but  a  few  large  vessels  could  still  be  observed  coursing  behind  the 
manubrium.  He  could  inflate  the  tympanal  membrane  after  the 
manner  described  in  the  former  cases.  The  hearing  distance  had 
increased  to  fourteen  inches ;  the  noise  had  very  much  lessened,  and 
occasionally  intermitted  altogether.  The  sm'face  of  the  membrana 
tympani  was  again  washed  over  with  the  solution  of  caustic,  and  the 
walls  of  the  meatus  smeared  with  brown  citrine  ointment,  applied  in  a 
melted  condition. 

The  chronic  inflammation  of  the  entire  external  auditory  aperture 
in  this  case  appears  to  have  been  the  result  of  mechanical  pressure, 
and  the  irritation  of  the  hardened  wax. 

INFLAMMATIONS   OF   THE    EXTERNAL   AUDITORY   CANAL. 

Inflammations  of  the  external  meatus  and  auditory  canal  are  of 
very  common  occurrence.  To  follow  out  the  anatomical  principle  of 
classification  pm-sued  by  some  authors,  these  inflammations  should  be 
di-sided  according  to  the  structm-e  in  which  they  have  their  seat ;  but, 
as  all  practical  surgeons  are  well  aware,  it  is  no  more  possible  to  do 
so  than  to  limit  the  spread  of  these  inflammations.  Thus,  what  may 
commence  as  a  simple  inflammation  of  the  tegumentary  tissue,  may 
end  in  caries  of  the  bone  and  inflammation  of  the  brain  or  its  mem- 
branes. I  have,  therefore,  adopted  the  arrangement  specified  in  the 
nosological  chart,  and  of  which  the  following  is  a  des-cription  : — 

Abscess  in  the  external  meatus  is  one  of  the  most  painful  and  fre- 
quent inflammations  of  the  external  ear.  Generally  it  is  not  like  the 
diffused  form,  the  result  of  cold,  but  seems  to  be  induced  by  some 
peculiar  state  of  the  constitution,  and  very  often  appears  either  as 
the  sequel  to  or  a  concomitant  of  boils  on  other  parts  of  the  body, 
particularly  about  the  neck.  These  abscesses  are  more  frequent  in 
females  than  in  males ;  and,  I  am  inclined  to  think,  appear  oftener  in 


192      INFLAMMATIONS    OP    THE    EXTERNAL    MEATUS. 

persons  of  tlie  upper  walks  of  life  than  those  in  the  lower.  They 
may  he  seated  anywhere  all  round  the  external  meatus,  but  occur 
more  frequently  in  the  anterior  and  posterior  wall  than  in  the  roof  or 
floor.  They  may  not  exceed  a  pea  in  size,  or  they  may  advance  to 
that  of  a  large  marble,  or  even  a  walnut,  when,  if  seated  anteriorly, 
they  spread  in  front  of  the  tragus,  and  if  posteriorly,  thoy  present  a 
considerable  protuberance  over  the  mastoid  process,  so  as  to  be  dis- 
tinguished with  some  difficulty  from  inflammation,  and  deposits  of  pus 
beneath  the  periosteum  in  that  situation.  They  seldom  or  ever  ap- 
pear singly :  there  is  generally  a  succession  of  them,  and  of  this  the 
patient  should  be  informed  on  first  applying  for  advice.  There  is  not 
much  redness  of  the  part ;  the  heat  is  more  of  a  burning  or  itching 
character.  The  pain,  however,  is  most  intense,  aggravated  by  the 
slightest  touch,  and  always  increased  at  night,  and  also  by  any  mo- 
tion of  the  jaw.  In  addition,  there  is  always  more  or  less  tinnitus, 
and  a  feeling  of  stuffing,  buzzing,  and  throbbing  in  the  ear.  The 
fever  is  at  times  considerable — much  more  so  than  would  be  expected 
from  so«slight  a  cause,  and  characterized,  not  so  much  by  alteration  in. 
the  circulation,  as  by  evening  paroxysms,  heat  of  skin,  restlessness, 
and  great  anxiety  of  countenance.  From  the  structures  in  which 
they  are  placed,  these  abscesses  are  generally  a  long  time  coming  to 
the  surface,  and  they  almost  invariably  point  internally,  or  toward 
the  centre  of  the  external  orifice.  The  contents  of  each  abscess — 
which  is  the  analogue  to  a  stye  upon  the  eyelid,  but,  owing  to  the 
structure  in  which  it  is  placed,  it  is  far  more  painful — consists  of  thick 
yellow  pus  and  a  hard  core  of  dead  cellular  membrane ;  the  former  is 
sometimes  only  a  drop,  at  other  times  it  is  as  much  as  a  drachm. 

The  local  treatment,  most  efficacious  for  preventing  suppuration  in 
these  parts  when  inflammation  has  been  set  up,  is  the  application  of 
the  solid  nitrate  of  silver  so  as  to  blacken  the  skin.  As  soon  as  we 
believe  matter  has  formed,  and  come  some  way  to  the  surface,  but 
not  till  then,  we  should  make  an  incision  with  a  very  small  double- 
edged  knife.  At  the  same  time  fomentations  and  poultices,  and  hold- 
ing the  ear  over  the  steam  of  hot  water,  will  afford  relief  both  before 
and  after  the  matter  has  been  evacuated. 

Few  diseases  of  the  ear  require  more  careful  constitutional  treat- 
ment than  this.  After  attention  to  the  state  of  the  digestive  organs 
in  the  usual  fashion,  the  use  of  bark,  with  either  the  liquor  potassse 
or  Brandish's  alkaline  liquor,  will  assist  to  prevent  a  recurrence  of 
these  abscesses.     While  the  abscesses  in  the  external  meatus  are  ap- 


INFLAMMATIONS     OF     THE     EXTERNAL     MEATUS.        193 

pearing  in  tlie  manner  described  above,  there  is  generally  some  sub- 
acute inflammation  of  the  lining  of  the  whole  canal,  attended  with  a 
whitish  discharge,  and  in  some  cases  the  membrana  tympani  is  itself 
inflamed,  so  that  we  should,  as  soon  as  the  parts  will  permit,  examine 
the  condition  of  that  structure.  If  inflamed,  leeches  are  indicated ; 
but  unless  applied  in  the  very  early  stage  of  circumscribed  inflamma- 
tion, they  seldom  prevent  the  formation  of  matter. 

Diffused  inflammation  of  the  external  meatus  is  a  matter  of  much 
more  serious  consequence  than  either  the  profession  or  the  public  are 
aware;  for,  frequently  as  it  occurs,  and  lightly  as  it  is  treated,  it 
generally  ends  in  the  establishment  of  a  disgusting  disease — otorrhoea, 
which  always  impairs  the  hearing,  oftentimes  leads  to  total  deafness, 
and,  in  some  cases,  ends  i];i  death.  Yet  how  frequently  do  we  hear 
practitioners  speak  of  the  patient  having  "  only  a  slight  discharge 
from  the  ear."  At  times  the  symptoms  of  inflammation  of  the  lining 
of  the  meatus  are  so  slight,  and  produce  such  little  uneasiness,  that 
the  patient  first  becomes  conscious  of  his  disease  by  feeling  something 
wet  in  his  ear,  when  upon  applying  the  finger,  or  a  towel,  he  disco- 
vers that  a  discharge  of  thin,  whitish,  muco-purulent  matter  has  been 
established ;  or  in  infants  and  young  children,  about  the  period  of 
dentition,  the  nurses  and  attendants  observe  the  flow  of  matter  as  the 
earliest  symptom  of  the  disease.  This  is  the  subacute  or  catarrhal 
inflammation  of  the  dermis,  and  the  external  layer  of  the  membrana 
tympani,  which  is  always  attended  with  otorrhoea,  and  which  fre- 
quently remains  in  a  chronic  condition  for  years.  The  state  of  the 
external  aperture  on  the  first  onset  of  the  disease,  and  before  it  has 
become  thickened  or  excoriated  by  the  discharge,  is  normal ;  but  within 
the  cuticle  is  white,  pulpy,  and  detached,  and  the  skin  beneath  it  is 
usually  of  a  pinkish  color.  Tliis  is  a  disease  of  infancy  and  youth, 
and  is  one  of  the  most  decidedly  strumous  affections  with  which  I  am 
acquainted,  not  only  from  its  appearing  in  persons  of  well-marked 
scrofulous  character,  but  from  its  being  so  frequently  a  concomitant 
of  other  scrofulous  aff"ections,  particularly  of  the  lungs.  Out  of  2385 
cases  recorded  in  the  Table  at  page  108,  there  were  516  of  chronic 
otorrhoea,  the  males  predominating  somewhat  over  the  females. 

Acute  inflammation  diffused  over  the  external  meatus  may  be  either 
idiopathic,  as  from  cold ;  traumatic,  from  a  foreign  body  or  any  irri- 
tating substance  introduced  into  the  meatus;  or  specific,  as  when  it 
occurs  in  the  course  of  some  of  the  exanthematous  fevers,  is  produced 
by  infection  with  gonorrhoeal  matter,  or  is  attended  by  such  other 

13 


194      INFLAMMATIONS     OF    THE    EXTERNAL    MEATUS. 

symptoms  in  persons  wliere  there  is  a  decided  diathesis  that  it  may  be 
termed  rheumatic.  This  latter  need  not  end  in  suppuration  or  otor- 
rhoea;  the  previously  specified  forms  generally  do.  To  these  different 
forms  of  inflammation,  classified  in  the  nosological  chart  at  page  151, 
I  have  added  that  of  periosteal,  to  define  that  particular  kind  of  inflam- 
mation usually  accompanied  "vvith  otorrhosa,  which,  sooner  or  later, 
spreads  to  the  periosteum  and  the  bone  of  the  auditory  canal,  and 
from  thence  to  neighboring  structures,  often  producing  fatal  conse- 
quences. When  once  a  discharge  is  established,  no  matter  from  what 
cause,  but  more  particularly  when  it  results  from  subacute  or  chronic 
inflammation  of  the  lining  of  the  meatus,  and  the  external  surface  of 
the  membrana  tympani, — which,  in  such  cases,  generally  becomes 
muco-secreting, — we  have  then  a  special  disease  to  treat,  denominated 
external  otorrhosa,  which  shall  be  considered  in  the  chapter  upon  that 
subject. 

Acute  inflammation  of  the  meatus  can  scarcely  exist,  or  proceed  to 
any  extent,  without  engaging  the  external  layer  of  the  membrana 
tympani.  The  inflammatory  action  may  be  limited  to  these  two  situ- 
ations ;  where  known,  the  disease  is  characterized  by  violent  pain  and 
fever,  it  seldom  is  so,  but  usually  engages  the  mucous  membrane  of 
the  cavity  of  the  tympanum,  as  is  proved  by  the  frequent  rupture  of 
the  membranous  diaphragm  between  these  tvfo  portions  of  the  auditory 
apparatus.  Such  is  generally  the  case  in  those  inflammations  attend- 
ing eruptive  fevers,  scarlatina  in  particular,  where  the  mucous  mem- 
brane of  the  throat  and  ear,  as  well  as  the  glandular  structures  of  the 
neck,  are,  in  severe  instances  of  that  affection,  so  frequently  engaged ; 
but  in  these  latter  I  am  inclined  to  think  the  disease  spreads  to  the 
auditory  organ  more  frequently  from  the  throat  than  the  skin. 

Acute  inflammation  of  the  meatus  is  characterized  at  first  by  dry- 
ness, itching,  and  heat  of  the  part,  gradually  increasing  to  a  dull 
aching,  and  eventually  to  an  acute  lacerating  pain,  generally  increased 
at  night,  and  in  some  instances  amounting  to  insufferable  agony,  with 
loss  of  rest,  fever,  and  even  delirium.  The  lining  of  the  meatus  is 
swollen:  at  first  dry  and  pinkish,  then  white  and  muculent;  and  at 
that  stage  I  have  on  several  occasions  seen  the  whole  of  the  bony 
portion  of  the  tube  and  the  external  surface  of  the  membrana  tym- 
pani coated  with  a  layer  of  plastic  lymph.  In  a  short  time  a  sero- 
mucous  or  muco-purulent  discharge  is  established,  or  yellow  pus 
pours  from  the  meatus,  and  relief  is  then  generally  experienced.  At- 
tendant upon  these  feelings  and  appearances  there  is,  particularly  in 


INFLAMMATIONS     OF    THE     EXTERNAL     MEATUS.       195 

rheumatic  cases,  a  sensation  of  soreness  over  that  side  of  the  head, 
and  all  the  symptoms  are  increased  by  sneezing,  coughing,  chewing, 
or  moving  the  jaw  in  any  manner.  As,  however,  the  hemicranial 
pain,  and  many  of  the  other  symptoms  detailed,  are  common  to  in- 
flammations of  the  cavitas  tympani  and  general  otitis,  it  is  often  diffi- 
cult to  distinguish  external  from  internal  inflammation  of  the  ear. 
The  following  case  of  acute  inflammation  of  the  external  auditory 
tube  and  membrana  tympani  (No.  16  in  the  Registry),  is  characteristic 
of  this  affection : — 

T.  S.,  aged  46,  a  shopman,  complains  of  deafness  in  his  left  ear,  of 
a  fortnight's  duration,  accompanied  by  a  buzzing  noise  and  throbbing. 
The  disease  commenced  late  in  the  evening,  with  severe  pain,  which 
continued  all  night,  and  which,  although  mitigated,  has  never  entirely 
ceased  since,  but  is  always  most  distressing  at  night.  Upon  the  fifth 
or  sixth  day  he  perceived  a  "  slight  moisture  "  in  his  ear,  but  was  not 
conscious  of  any  sudden  burst,  or  a  feeling  as  if  something  had  given 
way  within.  The  external  meatus  and  auditory  tube,  as  well  as  the 
surface  of  the  membrana  tympani,  are  coated  over  Avith  a  tenacious 
muco-cerumenous  discharge,  upon  the  removal  of  which  the  entire 
surface  brought  into  view  appears  of  a  florid  red,  becoming  pinkish 
and  spotted  with  white  on  the  face  of  the  membrana  tympani.  Flakes 
of  cuticle  adhere  to  the  w^alls  of  the  canal.  The  spots  on  the  mem- 
brana tympani  appear  to  be  patches  of  lymph  effused  on  its  surface ; 
they  are  more  of  a  yellow  color  than  the  specks  of  cuticle  on  the  tube. 
The  membrana  tympani  is  still  imperforate.  We  occasionally  find 
the  whole  surface  of  the  tympanal  membrane  covered  over  with  a 
sheet  of  lymph  like  that  which  lines  the  trachea  in  cases  of  croup. 
He  cannot  hear  the  watch  even  on  touching.  On  the  right  side  the 
parts  are  healthy,  and  the  hearing  good.  The  treatment  recom- 
mended to  the  patient  has  only  aggravated  his  disease, — brandy  and 
oil,. laudanum,  hot  salt,  and  various  stimulating  applications,  having 
been  poured  into  the  meatus. 

This  is  a  case  too  manifest  to  be  mistaken ;  and,  from  the  total  loss 
of  hearing  upon  the  left  side,  it  is  probable  that  the  inflammatory 
action  has  extended  to  all  the  layers  of  the  membra,na  tympani,  and 
has  also  passed  into  the  cavity  of  the  middle  ear.  Had  it  commenced 
in  the  latter,  the  pain  and  attendant  fever  would  have  been  greater, 
and,  on  suppiu'ation  taking  place,  the  membrana  tympani  would  pro- 
bably have  been  ruptured  to  allow  the  exit  of  the  matter,  and  the  case 
would  now  be  one  of  internal  otorrhoea,  with  perforation.     Cases  of 


196      INFLAMMATIONS    OF    THE    EXTERNAL    MEATUS. 

this  nature  are  very  common  during  the  winter  months,  or  when  cold 
east  winds  prevail  in  March  and  April;  and  are  frequently  induced 
by  travelling  upon  the  top  of  a  coach,  sitting  opposite  an  open  door 
or  a  broken  window,  or  being  exposed  to  a  draft  of  cold  air  in  any 
situation.  I  am  frequently  consulted  by  Roman  Catholic  clergymen 
during  the  season  of  Lent,  for  inflammation  of  the  ear  acquired  while 
sitting  in  the  confessional-box,  often  for  hours  together,  in  cold,  ex- 
posed places  of  worship,  v/ith  the  ear  applied  to  a  small  aperture 
through  which  the  wind  is  playing.  In  the  foregoing  case,  local  de- 
pletion, continued  counter-irritation,  and  alterative  doses  of  mercury, 
restored  the  parts  to  a  healthy  condition,  and  the  hearing  returned. 
In  some  cases  of  inflammation  of  the  auditory  canal,  the  auricle  is 
hot  and  swollen ;  but  in  no  instance  does  it  ever  assume  the  oedema- 
tous  character  which  the  eyelids  present  in  severe  ophthalmia. 

The  treatment  of  acute  inflammation  of  the  external  auditory  con- 
duit should  be  strictly  antiphlogistic.  Local  depletion,  by  means  of 
leeches  applied  round  the  meatus,  or  the  neighborhood  thereof,  after 
the  manner  described  at  page  93,  is  indicated  in  almost  every  case. 
Purgation  is  always  attended  with  advantage,  and  the  patient  expe- 
riences great  comfort  from  the  application  of  heat  and  moisture. 
Mercury  is  seldom  indicated  unless  when  the  membrana  tympani  is 
deeply  implicated.  Counter-irritation  should  follow,  but,  unless  in 
mild  cases,  never  precede,  depletion.  Astringent  lotions  should  be 
used  with  caution  until  the  disease  is  in  a  subacute  or  chronic  form, 
when  it  becomes  a  case  of  ordinary  otorrhoea.  I  have  seen  small 
granulations  sprout  from  the  lower  portions  of  the  canal  within  eight 
or  ten  days  after  the  first  accession  of  inflammation  of  this  portion  of 
the  ear,  but  generally  speaking  they  occur  at  a  much  later  date,  and 
are  more  usually  attendant  on  disease  of  the  deeper-seated  structures. 
Superficial  ulcers  form  both  on  the  dermal  lining  of  the  meatus  and 
the  external  layer  of  the  membrana  tympani. 

Continental  authors  have  enumerated  gonorrhoea  among  the  causes 
of  inflammation  and  otorrhoea  from  the  external  meatus,  and  upon  the 
authority  of  writers  I  have  inserted  this  disease  in  the  nosological 
chart,  although  I  myself  have  never  met  a  case  that  could  be  fairly 
traced  to  it,  either  by  metastasis  or  the  direct  application  of  specific 
virus  to  the  part.  Mr.  Harvey,  of  London,  wrote  an  essay  on  vene- 
real aifections  of  the  ear,  in  the  London  Journal  of  Medicine  for 
February,  1852,  in  which  he  alludes  to  the  analogy  between  ophthal- 
mia neonatorum  and  infantile  otorrhoea  produced  by  the  contagion  of 


INFLAMMATIONS     OF     THE     EXTERNAL    MEATUS.       197 

specific  matter.  I  must,  however,  for  my  own  part,  confess  that  I 
am  miacquainted  with  that  "  obstinate  form  of  infantile  otorrhoea 
which  occurs  shortly  after  birth,  not  unfrequently  destroying  the 
organ,  and  producing  as  a  consequence  both  deafness  and  dumbness 
for  life,"  alluded  to  by  the  author.  In  order  to  trace  it  to  infection 
by  direct  contact,  the  disease  ought  to  appear  within  the  first  four- 
teen days  at  the  latest  after  birth,  whereas  every  accoucheur,  or  phy- 
sician familiar  with  the  diseases  of  children,  is  well  aware  that  the 
muculent  discharge  of  infants  does  not  in  general  appear  until  after 
the  second  month,  and  still  more  frequently  not  until  dentition  com- 
mences. The  case  related  by  Mr.  Harvey  does  not  support  his  hy- 
pothesis, or  bear  scrutiny.  A  man  laboring  under  gonorrhoea  and 
hernia  humoralis  is  "  seized  with  intense  itching  in  his  ear,  accom- 
panied with  paroxysms  of  pain  ;  and  shortly  afterwards  there  issued 
a  profuse  yellowish  discharge."  To  account  for  the  disease  the  au- 
thor says,  "  Let  us  suppose  the  man's  finger  to  have  been  soiled  with 
the  urethral  discharge,  and  that  on  an  occasion  of  an  intense  degree 
of  itching  in  the  internal  ear  (the  very  first  symptom  complained  of 
by  the  patient),  he  had  thoughtlessly  and  with  some  violence  thrust 
his  finger  into  the  meatus,  possibly  abrading  the  membrane  with  his 
nail."  He  also  quotes  Lincke's  description  at  length,  but  it  does  not 
contain  any  one  diagnostic  wherewith  to  distinguish  this  form  of  in- 
flammation from  that  arising  from  any  other  cause,  and  we  require 
experiments  to  establish  the  fact  that  the  external  meatus  is  suscepti- 
ble of  gonorrhoeal  infection. 

Whatever  may  be  the  cause  of  the  inflammation  in  the  lining  of 
the  meatus,  diseased  action,  once  set  up,  may  spread  sooner  or  later 
to  the  periosteum  and  the  bone,  causing  necrosis,  exfoliation,  cerebral 
disease,  and  death.  It  is,  therefore,  a  disease  at  all  times  demanding 
the  serious  attention  of  the  surgeon,  and  requiring  prompt  and  ener- 
getic measures  for  its  arrest.  Mr.  Toynbee,  in  an  elaborate  and  in- 
genious article  in  the  Medico-Chirurgical  Transactions,  vol.  xxiv., 
has  endeavored  to  show  that  disease  of  the  particular  portions  of  the 
ear  are  propagated  from  or  give  rise  to  disease  in  particular  portions 
of  the  brain ;  thus,  when  inflammation  or  its  results  is  seated  in  the 
external  meatus  or  mastoid  cells,  the  cerebral  aff'ection  will  be  found 
in  the  lateral  sinus  and  cerebellum  ;  from  the  tympanic  cavity,  disease 
is  propagated  to  the  cerebrum ;  and  from  the  labyrinth  to  the  medulla 
oblongata  and  base  of  the  brain.  The  author  has  collected  and  ar- 
ranged in  a  tabular  form  a  number  of  cases  of  death  produced  by 


198  CUTANEOUS    DISEASES    OF    THE    MEATUS. 

extension  of  disease  from  the  ear  to  the  brain,  or  its  membranes,  in 
which  post  mortem  examinations  were  made ;  but  although  these  cases, 
and  many  others  well  known  to  surgeons,  and  several  additional  ones 
recorded  by  members  of  the  profession  in  this  city,  to  which  I  shall 
have  occasion  to  refer  in  another  place, — all  prove  the  fatal  nature  of 
many  of  these  aural  affections, — they  certainly  do  not  establish  the 
theory  "  that  each  of  the  cavities  of  the  ear  has  its  particular  division 
of  the  encephalon  to  which  it  communicates  disease." 

CUTANEOUS    DISEASES    OF    THE    MEATUS. 

Diseases  of  the  skin,  particularly  herpetic  and  eczematous  eruptions, 
extend  from  the  auricle  into  the  meatus  ;  or  they  may  be  seated  in  the 
latter  alone.  In  either  case  the  treatment  is  similar.  If  allowed  to 
proceed  unchecked,  they  produce  thickening  of  the  lining  of  the  pas- 
sage, lessening  its  calibre,  and  in  time  steal  over  the  external  layer  of 
the  membrana  tympani.  As  the  result  of  the  chronic  inflammation, 
the  lining  of  the  meatus  becomes  thickened,  and  may  sometimes  be 
peeled  off,  like  the  detached  cuticle  of  a  blister  or  burn  upon  any  of 
the  exposed  surfaces  of  the  body.  There  is  a  th^'ck  pasty  matter,  not 
unlike  the  softened  cuticle  which  may  be  scraped  from  the  soles  of  the 
feet,  sometimes  coating  over  the  passage  :  and  occasionally  the  Avhole 
thimble-like  cuticular  lining  of  the  meatus  comes  out  en  masse.  In  all 
these  cutaneous  affections,  in  addition  to  the  treatment  already  referred 
to  when  they  are  seated  in  the  auricle,  great  benefit  Avill  be  derived 
from  the  application  of  a  solution  of  nitrate  of  silver, — ten  grains  to 
the  ounce  ;  and  subsequently,  when  the  lining  has  become  more 
healthy,  the  use  of  the  citrine  ointment,  referred  to  at  page  173. 
Bell,  in  his  work  on  Lues,  speaks  of  deafness  produced  by  a  "  scruffy 
eruption,"  and  sometimes  ulceration  of  the  external  auditory  passage, 
occurring  as  a  consequence  of  that  disease  ;  but  his  description  is  not 
sufficiently  accurate  to  be  de|)ended  up^n,  and  has  not  been  confirmed 
by  subsequent  observers.  No  doubt,  cutaneous  syphilitic  disease  will 
extend  by  ordinary  continuity  of  surface  into  the  meatus,  but  as  a 
special  form  I  am  unacquainted  with  it. 

I  have  seen  cases  of  intolerable  itching  of  the  meatus,  with  a  dry 
branny  state  of  the  cuticle,  lasting  for  months,  and  giving  rise  to 
heat  and  redness  of  the  auricle.  Paroxysms  of  the  disease  come  on 
at  stated  periods,  generally  in  the  evening.  Cases  of  this  nature,  and 
all  other  diseases  of  the  meatus,  attended  by  extreme  dryness  and  an 


CUTANEOUS    DISEASES    OF    THE    EXTERNAL    CANAL.      199 

unhealthy  state  of  the  cerumenous  secretion,  will  be  benefitted  by  the 
application  of  glycerine,  and  some  by  the  solution  of  gutta  percha 
in  chloroform. 

The  amount  of  hair  growing  round  the  meatus  and  attached  to  the 
posterior  surface  of  the  tragus  is  very  various.  Sometimes,  particu- 
larly in  persons  from  fifty  to  sixty  years  of  age,  the  vihrissce  fall  out, 
and  resting  either  on  the  meatus  or  membrana  tympani,  cause  intense 
annoyance,  and  at  times  produce  increased  redness  of  the  lining  of 
the  passage.  Syringing  affords  but  little  relief,  for  the  wet  hairs  only 
adhere  to  the  parts  more  intimately.  The  meatus  must  be  carefully 
inspected  with  the  speculum  under  strong  sunlight,  and  each  hair 
gently  removed  with  a  long  fine  forceps.  It  requires  some  delicacy 
of  manipulation  to  lift  a  hair  from  off  the  membrana  tympani  without 
giving  the  patient  pain  ;  but  it  is  the  only  effectual  remedy. 

Ulceration  of  the  meatus  is  of  itself  a  rare  disease  ;  but  it  is  a  fre- 
quent concomitant  of  other  affections,  such  as  otorrhoea,  or  the  irrita- 
tion of  substances  introduced  either  by  accident  or  for  curative  pur- 
poses. It  often  attends  chronic  erysipelas,  and  also  condylomatous 
growths  at  the  orifice  of  the  canal.  Extreme  cleanliness,  mild  astrin- 
gent washes,  the  application  of  nitrate  of  silver,  together  with  the 
constitutional  treatment  recommended  at  page  172,  will  generally  cure 
cases  of  this  description. 

MORBID    GROWTHS   AND   ALTERATIONS   IN   THE    EXTERNAL    AUDITORY 

CANAL. 

Variations  from  the  normal  calibre  of  the  external  meatus  may 
arise  from  a  number  of  causes, — viz.,  collapse  of  the  flexible  portion 
of  its  walls,  of  vfhicli  an  example  is  given  below ;  or  the  obverse  state, 
in  which  the  external  apertra-e  is  preternaturally  wide — a  common 
consequence  of  long-continued  otorrhoea  ;  stricture,  either  congenital 
or  acquired,  in  its  middle  part,  and  also  morbid  growths,  such  as  poly- 
pous, bony,  or  other  tumors. 

No.  20  in  the  Registry  is  a  case  of  closure  of  the  external  meatus ; 
in  T.  S.,  a  female,  aged  54,  AYho  says  she  became  deaf  gradually 
during  the  last  three  or  four  years.  Has  tinnitus  aurium  ;  but  no  pain 
or  soreness  in  the  ear.  There  is  little  to  be  learned  from  the  history 
of  this  case  ;  but  a  glance  at  the  external  ear  affords  a  tolerably  good 
idea  of  the  cause.  Upon  looking  at  the  meatus  we  perceive  that  it 
has  lost  its  usual  ovoid  shape,  and  has  become  a  mere   elongated  slit 


200  CLOSUKE    OF    THE    EXTERNAL    MEATUS. 

or  fissure  marked  by  a  dark  line  wkere  the  incurvated  edges  are  in 
contact.  Upon  drawing  forward  the  tragus,  we  rather  increase  the 
defect,  but  by  grasping  the  auricle  immediately  above  the  anti-tragus, 
and  drawing  it  outwards  and  a  little  forward,  we  can  to  a  certain  ex- 
tent restore  to  its  natural  size  and  position  the  external  auditory  aper- 
ture. The  hollow  formed  between  the  tragus  and  the  external  meatus 
is  much  larger  and  shallower  than  natural ;  and  on  pressing  with  the 
fingers  front  of  the  tragus  and  beneath  the  zygoma,  where  the 
skin  is  rather  corrugated,  we  are  unable  to  push  the  tragus  backwards 
into  the  concha  so  as  to  cover  the  meatus  externus,  to  which  in  normal 
cases  it  ought  to  act  as  a  sort  of  operculum.  Upon  examination  with 
the  speculum,  we  find  the  flexible  walls  of  the  auditory  tube  com- 
pressed, the  lining  of  the  passsage  white,  and  its  cuticular  investiture 
thickened  as  if  by  maceration,  and  detached  in  patches,  while  a  slight, 
whitish,  curdy  discharge  collects  round  the  edge  of  the  tubular  specu- 
lum. The  tympanal  membrane  is  white,  and  apparently  thickened. 
There  is  no  evidence  of  cerumenous  secretion  in  any  portion  of  the 
passage^ 

Upon  enlarging  the  external  meatus,  either  by  the  means  first 
pointed  out,  or  by  the  introduction  of  the  speculum,  the  hearing  is 
increased.  She  can  now  perceive  the  ticking  of  the  watch  at  six 
inches;  previously  she  only  heard  it  when  pressed  against  the  au- 
ricle. 

Closure  of  the  external  meatus  may  arise  from  a  variety  of  causes, 
of  which  I  possess  examples  in  an  extensive  series  of  drawings.  In 
the  instance  detailed,  it  does  not  seem  to  be  the  result  of  any 
inflammatory  process,  but  appears  to  have  been  caused  by  some 
force  gradually  exerted  upon  the  tragus,  drawing  its  point  forward 
toward  the  cheek,  and  pressing  its  base  backwards, — possibly  perma- 
nent spasm  of  the  tragicus  muscle.  It  is  a  very  slow  and  gradual 
process,  and  is,  therefore,  seldom  attended  to  by  the  patient  until 
complete  closure  of  the  meatus  ensues.  The  deficiency  of  cerumen, 
the  thickened  cuticle,  and  the  shght  discharge  observed  in  the  passage, 
are  the  result,  not  of  the  original  disease,  but  the  subsequent  closure 
and  pressure  of  the  sides  against  each  other.  It  is  a  disease  of  mid- 
dle or  advanced  age ;  and  although  it  attacks  one  ear  first,  it  gene- 
rally appears  in  that  on  the  opposite  side.  It  is  most  difiicult  to 
manage.  I  have  had  thoughts  of  making  an  incision  in  front  of  the 
tragus,  so  as  completely  to  divide  any  muscular  fibres  which  might 
have  produced  the  deformity ;  but  I  fear  that  plan  would  not  be  attended 


CLOSURE    OF    THE    EXTERNAL    MEATUS.  201 

with  mucli  success,  for  I  have,  from  long  experience,  remarked  that 
when  once  any  of  the  free  cartilages,  as  the  eyelids,  nose,  or  amicle, 
become  viciously  bent  or  distorted  from  their  natm^al  position  or  cur- 
vatm-e,  that  it  is  almost  impossible  to  restore  them  by  any  effort  of  art. 
I  have  used  tents  made  of  compressed  sponge  for  the  pm-pose  of 
gradual  dilatation,  but  I  cannot  say  that  I  have  effected  much  thereby ; 
they  should,  however,  be  given  a  fair  trial  in  every  case.  The  canal 
ought  to  be  cleansed  from  those  impra-ities  which  collect  therein,  and  the 
parts  washed  over  with  a  strong  solution  of  nitrate  of  silver,  and  a 
fresh  tent  should  be  introduced  every  night,  and  removed  in  the  morn- 
ing. With  intelligent  persons,  in  the  upper  ranks  of  life,  this  plan  of 
treatment,  if  proceeded  with  for  a  sufficiently  long  time,  will  be  at- 
tended with  benefit ;  but  with  careless,  stupid  people,  among  the  lower 
orders,  who  pay  little  attention  to  cleanliness,  it  has  but  a  slight 
chance  of  success.  Defective  hearing  arising  from  this  apparently 
mechanical  cause  is  one  of  the  few  diseases  that  may  be  relieved  by 
the  introduction  of  a  small  metallic  tube  shaped  like  a  wine-funnel. 
We  see  those  constantly  advertised  as  a  means  of  relieving  every  de- 
scription of  deafness.  I  need  not  say  that,  from  the  rarity  of  the 
pecuhar  disease  to  which  they  are  applicable,  how  very  few  cases  they 
can  afford  relief  to.  As,  however,  they  are  silvei'-gilt,  are  sold  in- 
very  neat  morocco  cases,  and  cost  a  guinea,  they  serve  the  purposes 
for  which  they  are  advertised:  they  do  not  cure  ;  they  only  sell. 
Baron  Larrey,  the  inventor  of  these  tubes,  supposed  that  the  disease 
which  they  are  intended  to  remedy  was  caused  by  loss  of  the  molar 
teeth  of  one  or  other  maxilla  in  early  life,  when  he  says  there  results 
a  "  gradual  displacement,  upwards  and  backwards,  of  the  condyles  of 
the  lower  jaw-bone,  which  sink  into  the  glenoid  cavities  of  the  tempo- 
ral bones  so  as  to  become  lodged  at  the  bottom  of  the  articular  cavi- 
ties, beyond  the  Glasserian  fissure,  and  before  the  meatus  externus, 
the  parietes  of  which  will  then  be  depressed  in  the  same  direction ; 
the  auditory  passage  is  gradually  obliterated,  or  undergoes  such  an 
alteration  that  the  rays  of  sound  can  no  longer  reach  the  tympanum, 
from  whence  results  deafness."  I  have  seen  cases  of  this  disease, 
however,  in  which  the  molars  had  not  been  lost. 

Several  years  ago  I  had  under  my  care  a  case  of  this  description, 
in  a  very  intelligent  old  gentleman,  and  having  made  an  accurate 
wax  cast  of  the  concha  and  meatus,  while  the  latter  was  drawn  open, 
as  already  described,  Mr.  Grimshaw  made  for  him  a  silver  tube, 
which,  fitting  accurately  to  the  parts,  gave  no  inconvenience,  was  not 


202     CONDYLOMA  OP  THE  EXTERNAL  MEATUS. 

remarkable,  and  very  much  imjDroved  the  hearing.  Pads  have  been 
constructed  to  fit  behind  the  ear,  and  press  the  auricle  forwards,  but 
they  do  not  afford  the  desired  relief.  Persons  who  are  aware  of  this 
cause  of  their  deafness  do  not,  when  conversing,  place  the  half-closed 
hand  behind  the  auricle,  in  order  to  collect  sound,  but  very  soon  learn 
how  to  enlarge  the  meatus,  by  drawing  the  auricle  outwards  and  a 
little  backwards. 

In  ordinary  cases  of  otorrhoea,  particularly  where  the  discharge  is 
profuse,  the  meatus  is  often  rather  larger  than  natural,  and  the  exco- 
riations, which  sometimes  occur  where  the  matter  is  of  an  ichorous 
character,  being  always  more  or  less  moist,  and  not  forming  crusts 
and  scabs,  do  not  produce  any  contraction  of  the  external  aperture ; 
but  other  cases  present  where  the  meatus  is  closed  by  morbid  growths, 
of  which  the  following  instance  is  an  example. 

Condyloma  of  the  external  meatus  is  a  rare  form  of  disease.  M. 
T>.  L.  (No.  21  in  Registry),  a  female,  aged  25,  suffers  from  deafness, 
tinnitus,  occasional  pain,  foetid  and  sometimes  bloody  discharge  from 
left  ear,  for  eight  months  ;  is  otherwise  healthy ;  attributes  her  affec- 
tion to  cold.  The  external  meatus  is  completely  closed  by  several 
condylomata  which  grow  around  its  margin,  but  particularly  from  its 
lower  edge.  They  are  rather  sensitive  to  the  touch,  lobulated  on 
their  surface,  project  a  considerable  distance  beyond  the  margin  of 
the  aperture,  and  are  a  little  more  florid  in  color  than  the  natural 
skin.  When  the  tragus  is  pressed  backwards  with  the  finger,  a  muco- 
purulent offensive  discharge  exudes  between  these  growths.  It  is  not 
possible  to  insert  even  a  small-sized  speculum  into  the  meatus  without 
causing  great  pain  and  irritation.  She  can  only  hear  the  watch  on 
touching.  The  right  ear  is  normal.  The  excrescences  were  touched 
with  solid  nitrate  of  silver,  after  which  a  poultice  was  applied.  The 
subsequent  treatment  consisted  in  washing  over  the  morbid  groAvths 
with  a  strong  solution  of  nitrate  of  silver  every  second  or  third  day, 
and,  in  the  intermediate  time,  keeping  a  dossil  of  fine  lint,  wet  with 
diluted  liquor  plumbi,  applied  to  the  concha ;  besides  the  internal  ad- 
ministration of  Piummer's  pill  and  sarsaparilla.  By  persisting  in 
this  treatment  for  upwards  of  two  months,  the  condylomata  disap- 
peared, leaving  the  meatus  natural,  when  the  membrana  tympani  was 
found  unimpaired,  and  the  hearing  was  restored. 

The  following  case,  No.  24  in  the  Registry,  presented  an  uncom- 
mon form  of  tumor  in  the  meatus : — 

M.  ]Sr.,  a  female,  aged  47,  has  been  deaf  of  the  right  ear  for  many 


EXOSTOSIS  OF  THE  EXTERNAL  MEATUS.      203 

years,  and  is  mucli  annoyed  by  itching  and  a  stuffed  feeling  in  the 
meatus.  A  tumor,  in  shape,  size,  and  color  resembling  a  half-ripe 
mulberry,  occupies  the  anterior  and  lower  edge  of  the  meatus,  a.nd 
extends  some  way  into  the  auditory  tube,  which  it  almost  completely 
blocks  up.  It  is  not  imlike  that  disease  known  here  as  "button 
scm-yy,"  and  to  which  the  late  Dr.  Wallace  of  this  city  gave  the 
name  of  morula.  It  is  attached  by  its  broad  base  throughout  its 
whole  extent,  and  has  neither  enlarged  nor  extended  for  the  last  five 
years,  during  which  time  I  have  been  in  the  habit  of  examining  it  oc- 
"casionally.  The  patient  never  had  otorrhoea ;  and  there  is  no  dischage 
now  present,  but  at  times  the  tumor  becomes  painful  and  irritable, 
and  then  its  color  deepens  from  a  florid  red  to  a  purple.  It  is  of  a 
firm  consistence,  corrugated  on  its  surface,  and  has  an  unyielding  feel, 
quite  unlike  a  nsevus,  for  which  at  first  sight  it  might  be  mistaken. 
I  have  not  meddled  with  this  tumor,  as  I  once  saw,  and  have  described 
at  page  205,  an  afiection  somewhat  similar  in  external  appearance,  in 
a  lady  about  this  woman's  time  of  life,  end  in  malignant  disease, 
apparently  hastened  by  treatment. 

We  meet  with  various  other  growths  in  the  external  meatus  and 
auditory  tube,  independent  of  polypus  or  other  morbid  products, 
resulting  from  inflammation  or  its  consequences.  One  of  the  most 
frequent  of  these  is  exostosis,  of  which  I  have  seen  very  many  exam- 
ples. The  projection  generally  grows  from  the  posterior  edge  of  the 
osseous  portion  of  the  tube,  and  slowly,  but  gradually  projects  for- 
wards, so  as  to  leave  but  a  slight  crescent-shaped  fissm^e  between  it 
and  the  anterior  wall  of  the  meatus.  The  integuments  covering  such 
growths  are  generally  very  smooth,  white,  and  polished.  I  have  sel- 
dom seen  this  disease  affect  both  ears,  but  I  have  often  remarked  it  in 
connexion  with  inflammatory  affections  both  of  the  external  tube  and 
the  membrana  tympani.  Autenrieth  has  given  an  account  of  one  of 
these  growths ;  and  in  1849  Mr.  Toynbee  communicated  a  valuable 
paper  on  the  subject  to  the  Provincial  Lledical  and  Surgical  Journal, 
giving  an  account  of  twelve  cases.  That  paper  is  illustrated  with 
woodcuts  representing  views  and  sections  of  a  portion  of  the  tempo- 
ral bone  in  a  dry  state,  exhibiting  in  particular  the  mastoid  process, 
and  a  section  of  the  bony  meatus,  in  order  to  show  the  position  of  the 
encroachments  made  by  these  morbid  growths.  I  do  not  think  it  at 
all  unlikely  that  the  temporal  bones  of  the  various  persons  alluded  to 
in  Mr.  Toynbee's  paper  may,  after  death,  present  the  appearances 
which  he  has  delineated :  and  the  diagrams  showing  the  form  of  the 


20-1      EXOSTOSIS  OF  THE  EXTERNAL  MEATUS. 

meatus,  and  the  amount  of  bony  growth  therein,  are,  no  doubt,  per- 
fectly allowable ;  but  I  am  not  so  well  satisfied  with  illustrations  of 
any  kind  except  such  as  are  absolutely  drawn  from  nature.  The 
treatment  recommended  for  these  growths  is  the  application  of  iodine  : 
when,  however,  the  disease  has  advanced  to  any  extent,  I  have  not 
much  faith  in  any  remedy ;  but  in  the  early  stage,  when  the  exosto- 
sis is  probably  the  result  of  chronic  periostitis,  local  depletion,  coun- 
ter-irritation, and  mercurials,  will  arrest  its  progress.  Fortunately, 
these  little  bony  nodules,  which  very  much  resemble  the  excrescences 
which  grow  from  the  beech  tree,  are  usually  of  very  slow  growth.  I 
know  one  which  has  not,  apparently,  increased  during  the  last  eight 
years.  On  the  contrary,  I  may  mention  having  just  seen  a  case,  in 
consultation  with  Dr.  Morgan,  in  a  gentleman  who  asserts  that  he 
heard  quite  well  with  both  ears  tAvelve  months  since ;  he  then  began 
to  lose  the  hearing  of  the  right,  which  is  now  quite  gone.  A  few 
months  ago  the  left  was  similarly  attacked,  and  he  can  only  hear  with 
that  ear  by  inserting  the  finger  for  some  distance  into  the  concha, 
and  forcibly  drawing  the  tragus  downwards.  Being  much  occupied 
with  business,  he  paid  no  attention  to  his  disease ;  •  at  least  he  sought 
no  advice  for  it  until  the  past  week.  Yet  this  is  a  gentleman,  I  am 
told,  of  considerable  professional  acquirements,  and  conducting  an  ex- 
tensive business.  It  seems  almost  incredible  with  what  apathy  and 
indifference  men  reputedly  clever  will  permit  their  hearing  to  be  lost 
without  making  any  effort  for  its  restoration.  But,  although  they 
have  allowed  the  day  of  grace  to  pass  by,  many  of  them  are  not  slow 
in  enlightening  society  upon  the  subject  of  the  impossibility  of  curing 
deafness,  or  their  complete  want  of  faith  in  medicine.  In  the  case  of 
Mr.  B.,  just  alluded  to,  the  external  meatus  on  the  right  side  is  com- 
pletely closed  by  a  hard,  smooth  exostosis  growing  from  its  posterior 
bony  wall,  and  filling  up  the  canal  so  perfectly  that  no  vestige  of  it 
can  be  seen  except  a  crescentic  line  where  the  new  growth  meets  the 
anterior  wall.  He  cannot  hear  the  watch  even  when  pressed  against 
the  auricle.  The  progress  of  the  disease  has  not  been  attended  with 
pain,  and  the  gentleman  is  in  perfect  bodily  health.  Upon  the  left 
side  he  can  hear  the  watch  when  pressed  against  the  auricle,  there 
being,  fortunately  for  the  patient,  two  exostoses,  which,  meeting  by 
their  convex  surfaces,  have  prevented  complete  closure  of  the  inferior 
portion  of  the  meatus,  and  as  there  are  still  manifestations  of  inflam- 
matory action  going  forward  in  the  meatus,  treatment  holds  out  a 
hope  of  improvement.     (See  page  208.) 


MALIGNANT    DISEASES    OF    THE    MEATUS.  205 

Schmalz  has  figured  a  small  exostosis  from  the  work  of  Platernus, 
which  grew  within  the  vestibule  ;  and  several  instances  have  been 
recorded  of  exostoses  within  the  csbYitj  of  the  tympanum. 

When  otorrhoea  has  been  long  established,  or  that  caries  has  taken 
place,  fistulous  openings  form  between  the  external  meatus  and  the 
mastoid  or  aural  regions.  In  the  former  situation  they  are  not  at  all 
uncommon  ;  I  have,  in  two  instances,  seen  sinuses  five  inches  in 
length,  extending  from  the  external  auditory  canal  along  the  side  of 
the  neck,  and  not  long  since  there  was  a  patient  at  the  Hospital  labor- 
ing under  phthisis  and  otorrhoea,  who  could  pump  the  matter  out  of 
his  ear  by  pressing  upon  an  abscess  situated  over  the  upper  edge  of 
the  scapula. 

Polypi  in  the  external  meatus  are  very  common,  and  generally 
grow  from  some  part  of  the  bony  portion  of  the  canal.  As  they  are 
always  attended  with  otorrhoea,  they  shall  be  considered  in  the  chap- 
ter devoted  to  that  subject.  The  consideration  of  caries  also  belongs 
to  the  chapter  upon  otorrhoea. 

MALIGNANT    DISEASES    OF    THE    MEATUS. 

Malignant  diseases  in  the  external  meatus  are  very  rare,  although 
they  may  engage  that  part  in  some  stage  of  their  progress.  Of  lupoid 
ulcerations,  and  cutaneous  cancer,  I  have  already  spoken  at  page  175. 
Osteosarcoma  of  the  lower  jaw  or  the  malar  bone  sometimes  encroaches 
upon  the  meatus,  as  may  be  seen  in  the  morbid  specimens  in  our 
museums.  The  following  case  is  worthy  the  attention  of  the  surgeon, 
as  it  shows  us  how  careful  we  should  be  in  meddling  with  morbid 
growth  of  long  standing,  without  being  fully  satisfied  as  to  their 
nature  and  the  place  from  which  they  grow. 

A  female,  aged  about  50,  whose  brother  I  subsequently  heard  had 
died  of  cancer,  consulted  me  some  years  ago  on  account  of  a  polypous 
growth  in  the  right  ear,  attended  with  a  remarkably  foetid  discharge 
of  many  years'  duration.  She  had  an  unhealthy  look,  and  complained 
occasionally  of  giddiness,  loss  of  rest,  and  sickness  of  stomach.  The 
otorrhoea  having  increased  considerably  of  late,  she  was  anxious  to 
have  it  removed  if  possible.  The  meatus  was  filled  with  a  large  red- 
dish-brown flabby  polypus,  much  darker  in  color  than  I  had  ever  seen 
before.  On  examination  I  found  it  firmly  attached  to  the  lower  and 
posterior  wall  of  the  external  meatus,  and  I  could  not  lift  it  up  or 
pass  a  probe  round  it,  as  can  generally  be  efiected  in  ordinary  cases 


206  MALIGNANT    DISEASES    OE    THE    MEATUS. 

of  polypus,  no  matter  of  liow  long  standing.  Neither  did  it  present 
tlie  circular  protuberance  which  forms  in  cases  of  fibrous  polypus  as 
soon  as  the  morbid  growth  has  cleared  the  meatus  and  commenced  to 
mould  itself  into  the  shape  of  the  external  aperture.  It  was  not 
possible  to  examine  the  canal,  so  completely  did  the  morbid  growth 
fill  it  up,  but  a  probe  could  be  passed  with  facility  all  round  its  upper 
and  anterior  surface.  These  were  the  only  symptoms  which  presented 
when  I  first  saw  her.  She  stated  that  she  had  latterly  sufii"ered  from 
pain  in  the  ear,  and  that  upon  several  occasions  during  the  past  year 
pieces  of  the  polypus  had  come  away.  Finding  it  impossible  to  pass 
a  snare  round  it,  I  removed  a  portion  of  it  with  a  scissors,  and  the 
hemorrhage  which  foUovfed  was  inconsiderable.  Subsequently  I 
attempted  to  lessen  the  growth  by  the  ajDplication  of  nitrate  of  silver 
applied  to  its  surface,  and  also  by  passing  a  small  sharp-pointed  probe, 
coated  with  the  caustic,  through  its  surface.  Constitutional  treatment 
calculated  to  improve  the  patient's  health  was  not  neglected  ;  and  for 
a  short  time,  the  local  appearances  improved,  but  I  was  never  able  to 
clear  the  meatus  of  the  morbid  growth.  My  attention  was  soon 
attracted  by  the  rapid  progress  of  the  fungoid  mass,  which  increased 
almost  as  quickly  as  it  was  removed.  In  the  course  of  a  month  the 
serious  nature  of  the  disease  manifested  itself.  The  growth  from  the 
meatus  assumed  a  livid  unhealthy  color.  The  auricle  was  pressed  for- 
ward and  outward  by  a  fluctuating  tumor  over  the  mastoid  process. 
This  I  opened,  and  a  quantity  of  dark-colored  foetid  matter  was  evacu- 
ated, and  considerable  relief  experienced  for  a  short  time.  Paralysis 
of  that  side  of  the  face  next  appeared ;  several  large  abscesses  formed 
along  the  course  of  the  mastoid  muscle  ;  well-marked  rigors  ensued, 
and  the  general  health  gave  way,  the  characters  of  malignant  disease 
being  strongly  marked  in  the  countenance.  Convulsions,  followed  by 
long  fits  of  com^a,  ensued,  and  the  pain  at  times  was  most  excruciating. 
The  post-aural  and  infra-aural  regions  rapidly  enlarged ;  the  integu- 
ments of  the  mastoid  region  gave  way,  and  a  large  fungoid  mass 
sprouted  therefrom,  which,  in  a  few  days,  attained  the  size  of  a  lemon. 
The  foetor  was  the  most  intolerable  and  sickening  I  ever  smelled,  and 
death  put  an  end  to  her  sufierings  in  about  three  weeks  after  the 
external  appearance  of  the  fungus,  which  presented  all  the  characters 
of  true  malignant  disease.  I  was  unable  to  obtain  a  post  mortem 
examination. 

Whether   benign  disease  can,  by  interference,  be  converted  into 
malignant,  has  not  yet  been  decided  by  pathologists.     Where  the  dis- 


'malignant  diseases  of  the  meatus.         207 

ease  originated  in  this  case,  it  is  not  possible  to  determine  ;  eventu- 
ally, however,  it  must  have  engaged  all  the  cavities  and  structures  of 
the  ear.  The  only  point  in  which  this  case  differed  from  one  of  ordi- 
nary polypus,  resulting  from  chronic  inflammation  and  otorrhoea, 
when  I  first  saw  it,  was  in  the  attachment  of  the  growth  to  the  exter- 
nal and  posterior  lip  of  the  meatus. 

The  following  case,  for  the  particulars  of-  which  I  am  indebted  to 
Mr.  Cusack,  occurred  in  this  city  in  1843.  It  was  originally  pub- 
lished in  my  essay  on  otorrhcea,  but  is  so  similar  in  many  respects  to 
the  foregoing  that  I  insert  it  here. 

An  apparently  healthy  boy,  seven  years  of  age,  was  brought  to 
him  on  account  of  a  discharge  from  the  external  meatus.  Upon  ex- 
amination, a  small  polypus  was  discovered  in  the  passage  ;  this  was 
removed,  but  on  the  thii-d  day  following  it  was  found  to  have  grown 
as  large  as  ever  ;  it  was  again  repeatedly  removed,  and  the  usual 
slightly  astringent  washes  were  had  recourse  to  in  the  interim.  This 
polypous  or  fmigous  growth  did  not  present  anything  remarkable  ex- 
cept the  extraordinary  power  of  being  reproduced  in  a  day  or  two,  on 
which  account  it  was  no  longer  attempted  to  be  destroyed,  but  a  more 
palliative  mode  of  treatment  was  had  recourse  to.  Not  long  after, 
the  child  was  suddenly  seized  with  an  epileptic  fit ;  and  then  on 
closely  examining  the  ear,  a  fluctuating  point  was  discovered  over  the 
mastoid  process  ;  this  was  instantly  cut  down  upon,  and  the  opening 
gave  exit  to  a  large  discharge  of  pus.  It  was  then  found  that  the 
cavity  which  contained  this  matter  communicated  by  a  fistulous  open- 
ing with  the  external  auditory  tube  ; — a  fungous  mass  almost  imme- 
diately sprouted  through  the  incision  ;  the  parts  in  front  and  all  round 
the  ear  became  swollen,  and  had  that  peculiar  hoggy  feel  to  the  touch, 
which  left  but  little  doubt  regarding  the  malignant  natm-e  of  the 
disease.  The  original  am^al  polypus  remained  as  before,  but,  from 
the  struggles  of  the  child  and  the  condition  of  the  parts,  at  no  one 
period  was  it  possible  to  learn  with  accuracy  the  state  of  the  tympa- 
num. Repeated  attacks  of  epilepsy,  each  increasing  in  violence,  and 
the  intervals  shortening  in  duration,  followed  quick  upon  this  deplora- 
ble condition,  and  death  soon  closed  the  scene. 

Upon  examination  it  was  discovered  to  be  a  well-marked  case  of 

osteosarcoma  of  the  petrous  and  mastoid  portions  of  the  temporal 

"bone.     The  petrous  portion  in  particular  was  enormously  enlarged, 

and  so  softened  as  to  be  capable  of  being   cut  with  a  knife.     The 

whole  presented  a  large  fungous  mass,  which,  however,  did  not  engage 


208  MALIGNANT    DISEASES    OF    THE    MEATUS. 

that  portion  of  the  bram  which  lay  upon  it.  All  traces  of  the  internal 
ear  had  been  obliterated.  There  can,  I  think,  be  little  doubt,  but 
that  in  this  case  the  original  disease  was  seated  in  the  bone,  and  that 
the  aural  discharge  and  fungus  were  but  secondary  morbid  appear- 
ances. 

Dr.  Hutton  has  just  informed  me  that  he  had  lately  under  his  care 
a  case  of  chimney-sweepers'  cancer  of  the  external  ear. 

A  fortnight  after  the  note  of  Dr.  Morgan's  case  of  exostosis,  re- 
ferred to  at  page  204,  I  saw  Mr.  B.,  whose  treatment  had,  in  the 
interim,  consisted  in  leeching  the  meatus,  and  the  internal  administra- 
tion of  minute  doses  of  the  bichloride  of  mercury.  The  improvement 
was  truly  astonishing  :  the  protuberances  in  the  left  ear  had  lessened 
considerably,  and  the  hearing  was  nearly  restored  on  that  side. 

We  sometimes  meet  with  small,  white,  round  bodies,  the  size  of 
millet  seeds,  in  the  walls  of  the  meatus,  similar  to  those  frequently 
seen  about  the  eyelids. 

In  describing  the  diseases  of  the  auricle,  I  should  have  mentioned 
"  dislocation,"  of  which  a  remarkable  example  presented  at  South 
Carolina,  in  which  the  auricle  was  detached  from  its  seat,  and  carried 
downwards  on  the  surface  of  an  enormous  pendulous  tumor.  (See 
London  Medical  Repository,  1816.) 


209 


CHAPTER   V. 

DISEASES    OF   THE    MEMBEAXA   TTMPAXI. 

Anatomy  of  Membrana  Tympani. — Its  Congenita]  ^Malformations. — Injuries  of:  Rup- 
ture.— Inflammations:  Acute:  Rheumatic  Otitis. — Subacute  :  Syphilitic  :  Gouty. — Senile 
Deafness. — Strumous ;  with  Ophthalmia. — Exanthematous ;  Typhoid. — Chronic  Thick- 
ening and  3Iorbid  Deposits  in  Membrane. — Cutaneous  Diseases  :  Collapse,  with  Loss  of 
\'ibration. — Operation  of  Perforation. — Ulceration;  Apertures  in  Membrane  :  Total  De- 
struction of. — Artificial  Membrana  Tympani. 

The  membrana  tympani,  or  clram-liead,  separates  the  external 
meatus,  at  the  extremity  of  vrliicli  it  is  placed,  from  the  cavity  of  the 
tjmpanmn ;  so  that,  from  its  position  as  well  as  the  anatomical  con- 
nexion of  its  structures,  it  must  partake  of  the  diseases  of  hoth  tjarities 
independent  of  those  peculiar  to  itself.  It  is  a  thin,  semitransparent, 
di'v  membrane,  "of  an  irregular  oval  shape,  yarying  in  size  as  much  as 
the  cornea,  but  generally  measuring  about  eight-twentieths  of  an  inch 
in  its  longest  diameter,  which  is  in  a  diagonal  line  from  above  forwards 
and  downwards.  It  is  placed  obhquely  from  above  downwards,  and 
somewhat  from  before  backwards  and  outwards,  and  set  in  a  well- 
marked  groove  upon  an  elevated  ridge,  at  the  tympanal  margin  of 
the  bony  meatus,  like  the  crystal  in  the  besil  of  a  watch.  In  foetal 
life  this  tympanic  ring  is  a  separate  and  distinct  portion  of  the  tem- 
poral bone,  and  does  not  become  altogether  incorporated  with  it  until 
some  time  after  birth.  It  is  produced  from  a  separate  and  distinct 
point  of  ossification,  and  may,  therefore,  be  regarded  as  a  fom'th  divi- 
sion of  the  temporal  bone  superadded  to  those  ah'eady  enumerated  at 
page  154.  From  this  ring  grows  the  osseus  meatus  audrtorius  exter- 
nally, and  also  a  portion  of  the  floor  of  the  cavity  of  the  tympanum 
internally.  This  circle  is  never  completed,  as  may  be  seen  by 
examining  a  section  of  the  temporal  bone,  made  through  the  tvmpa- 
num,  immediately  behind  the  groove  for  the  attachment  of  the  mem- 
brane. It  remains  deficient  superiorly,  where  the  malleus  joins  the 
membrana  tympani,  and  at  which  point  the  head  of  that  bone  lies  in 

14 


210  ANATOMY    OF    THE    MEMBRANA    TYMPANI. 

the  superior  sinus  of  tlie  tympanum.  If  we  examine  a  number  of 
temporal  bones,  we  will  find  the  groove  for  the  membrane  deepest  at 
the  lower  and  back  part,  and  least  marked  above,  towards  the  part 
where  the  ring  is  generally  deficient. 

The  manubrium,  or  handle  of  the  malleus,  is  enclosed  for  about 
three-fourths  of  its  length  between  the  laminse  of  the  membrana  tym- 
pani,  which  are  partially  inserted  into  it.  This  process  of  the  ham- 
mer-bone serves  to  support  and  also  to  preserve  the  peculiar  curvature 
of  the  membrane,  as  well  as  to  convey  to  the  labyrinth  the  vibrations 
of  sound  which  impinge  upon  it.  At  birth  the  tympanic  ring,  with 
its  enclosed  membrane,  looks  obliquely  downwards  and  slightly  out- 
wards, and  it  is  only  by  the  formation  of  the  floor  of  the  tympanum 
that  the  position  which  it  assumes  in  adult  life  is  produced.  The 
membrana  tympani  is  also  proportionally  larger  in  the  foetus  than  in 
the  adult.  A  knowledge  of  these  relations  is  important  in  a  patholo- 
gical point  of  view,  as  they  show  how  easily  disease  of  the  meatus  or 
the  membrana  tympani  may  be  propagated  to  the  neighboring  parts. 

Viewed  through  the  speculum,  with  a  stream  of  clear,  direct  sun- 
light upon  it,  the  membrana  tympani  is  of  a  grayish  hue,  and  semi- 
transparent  consistence  ;  and  presents  externally  an  irregularly  curved 
surface,  as  also  dijfferent  degrees  of  density,  polish,  and  tension.  It 
is  divided  by  a  white  streak,  thickened  above  and  narrow  below,  except 
at  its  extremity,  which  is  slightly  enlarged  and  indented  into  a  navel- 
like depression.  This  white  opaque  line  is  the  manubrium  of  the 
malleus,  proceeding  from  the  upper  attachment  of  the  membrane 
downwards,  somewhat  backwards  and  a  little  inwards  to  a  point 
slightly  below  the  centre  of  the  membrane,  and  thus  divides  it  into 
an  anterior,  a  posterior,  and  an  inferior  portion.  But  the  exact 
situation  of  this  bone,  and  consequently  the  relative  proportions  of 
the  parts  which  it  divides,  present  great  diversity.  The  anterior 
part  of  the  membrane  is  thin, — almost  transparent,  or  as  clear  as  fine 
goldbeater's  skin, — highly  polished,  and  generally  convex — a  speck 
of  bright  light  being  reflected  from  its  most  prominent  part.  This 
may  be  called  the  anterior  vibrating  portion.  In  many  cases  the 
short  process  of  the  malleus  may  be  seen  as  a  small  round  dot  above 
the  manubrium,  where  the  membrane  curves  ofi"  into  the  roof  of  the 
meatus.  The  bottom  of  the  meatus,  it  should  be  remembered,  is 
funnel-shaped,  the  broad  end  of  the  funnel  being  towards  the  tym- 
panum. 

When  the  centre  of  the  membrane  is  under  examination,  its  anterior 


ANATOMY    or    THE    MEMBRAXA    TYMPANI.  211 

attachment,  behind  the  sharp  cui've  of  the  meatus,  cannot  at  the  same 
time  be  seen,  nor  until  the  tubular  speculum  is  turned  toAvards  it,  and 
the  head  of  the  person  examined  is  brought  into  the  proper  angle  ;  and 
the  same  remark  holds  good,  except  in  cases  of  very  large  meatus,  with 
respect  to  the  posterior  margin  ;  the  superior  and  inferior  attachments 
are  more  easily  observed ;  but  by  rotating  the  speculum,  and  altering 
the  head  from  side  to  side,  we  can  bring  in  succession  each  portion  of 
the  membrane  into  view.  The  relative  size  of  each  portion  of  the 
membrane  varies  in  different  individuals.  In  making  this  examination 
the  tube  should  not  be  inserted  much  beyond  the  middle  of  the  meatus. 
Below  and  behind  the  malleus  the  membrane  is  also  thin,  clear,  and 
glistening,  but  not  quite  so  diaphanous.  Beneath  the  point  of  the 
malleus  it  is  flat,  and  behind  it  rather  concave,  but  not  always  so. 
These  portions  do  not  usually  present  in  their  normal  state  spots  of 
reflected  light.  Superiorily,  from  about  the  upper  half  of  the  malleus, 
the  membrane  becomes  gradually  denser  until  it  is  quite  white ;  it 
also  forms  concave  curves  from  the  upper  part  of  the  malleus,  the 
posterior  one  being  deepest  and  whitest.  Above,  the  membrane 
forms  a  gradually  vaulted  curve  into  the  roof  of  the  external  auditory 
canal,  with  the  lining  of  which  it  is  imperceptibly  blended ;  while  in 
front,  below  and  partly  behind,  there  is  a  sharp,  well-defined  line  of 
demarcation  between  it  and  the  meatus,  and  sometimes  a  slight,  whitish 
thickening,  which  in  disease  and  some  old  persons  resembles  the  arcus 
senilis,  except  that  in  the  cornea  there  is  always  a  narrow  clear  space 
between  the  opacity  and  the  sclerotic.  In  some  persons  there  is  a 
slight  purse-like  projection  of  the  membrane  near  its  upper  attach- 
ment and  behind  the  tubercle  of  the  malleus — the  "membrana  flac- 
cida"  of  Sharpnell — rudimentary  in  man,  but  well  developed  in  some 
of  the  lower  animals.  The  speck  of  light  which  is  generally  reflected 
from  the  most  convex  and  prominent  portion  of  the  membrane  is  not 
always  in  the  centre  of  the  anterior  part,  but  is  often  seen  beneath  it. 
If  a  horizontal  section  of  the  membrana  tympani  be  made,  it  will 
present  somewhat  the  form  of  an  itahc  /,  the  middle  point  being  the 
ch'cular  flattened  extremity  of  the  manubrium  of  the  malleus. 

If  the  patient  under  examination  inflates  the  tympanum  after  the 
manner  described  at  page  74,  without  moving  the  head,  altering  the 
position  of  the  speculum,  or  in  any  way  deranging  the  light,  the 
whole  of  the  anterior  and  part  of  the  lower  portion  of  the  membrana 
tympani  is  bulged  outwards,  and  the  speck  of  light  appears  as  if 


212  ANATOMY    OF    THE    MEMBRANA    TTMPANI. 

spread  over  a  larger  surface,  or  is  entirely  lost  for  the  moment. 
Whether  the  membrane  is  then  rendered  more  or  less  tense  I  cannot 
satisfactorily  state.  In  some  cases  a  slight  elevation  or  outward 
pressure  of  the  malleus,  and  even  of  the  whole  membrane,  may  be 
observed.  If  the  inflation  be  continued,  the  upper  white  portion  fre- 
quently becomes  red,  and  vessels  can  be  seen  at  times  spreading  from 
it  along  the  sides  of  the  malleus. 

Great  diversity  of  opinion  exists  among  authors  with  respect  to  the 
curvature  and  general  appearance  of  the  healthy  membrana  tympani. 
They  almost  all,  however,  agree  in  pronouncing  it  a  uniform  conca- 
vity ;  but  this  I  believe  to  be  a  post  mortem  appearance.  One  of  the 
proofs  afforded  by  anatomists  of  the  external  concavity  of  membrana 
tympani  is, — that,  when  the  cuticular  lining  common  to  it  and  the 
meatus  is  removed  entire,  and  floated  in  water,  its  extremity  forms  a 
curved  pouch  like  the  finger  of  a  glove.  This,  however,  is  a  very 
fallacious  test ;  for,  if  we  take  the  finger  of  a  glove  and  invert  its  ex- 
tremity, so  as  to  present  a  marked  concavity  towards  its  internal  sur- 
face, we  can  easily,  either  by  blowing  into  it  or  drawing  it  through 
water,  make  it  assume  a  concave  appearance. 

Well  acquainted  as  every  person  familiar  with  the  character  which 
the  membrana  tympani  presents  upon  inflation,  it  will  appear  almost 
incredible  that  Dr.  Kramer  should  believe  that  even  a  forcible  stream 
of  air  from  the  air-press  cannot  alter  its  concave  form. 

It  is  of  great  importance  that  we  should  be  not  only  acquainted, 
but  familiar  with,  the  external  appearance  of  the  membrana  tympani 
in  a  normal  condition  ;  yet  how  many  practitioners  pass  through  life 
without  ever  having  seen  it  in  the  living  state  ! — all  they  know  of  it 
being  from  description  or  preparations  shown  them  during  their  ana- 
tomical studies.^ 

Behind  the  attachment  of  the  membrane  superiorily,  there  is  the 
head  of  the  malleus,  which  rises  above  it  into  a  large  hollow  in  the 
bone,  which  freely  communicates  with  the  mastoid  cells.  Anteriorly, 
and  somewhat  below  the  middle  line,  there  is  the  tympanic  opening 
of  the  Eustachian  tube,  opposite  the  portion  of  membrane  most  easily 
acted  upon  by  a  stream  of  air,  and  that  where  it  most  usually  gives 
way.     Below  and  behind  the  Eustachian  tube  is  the  carotid  canal, 

1  In  addition  to  the  foregoing  observations,  see  the  remarks  upon  the  membrana 
tympani,  at  p.  113.  See  also  the  author's  description  of  this  structure  in  the  Dublin 
Quarterly  Journal  of  Medical  Science,  vol.  xxiv.  p.  421.     1844. 


AXATOMY    OF    THE    MEMBEANA    TYMPANI,  213 

usually  perforated  in  that  part  of  the  posterior  curve  nearest  to  the 
membrana  tympani  by  a  small  aperture  for  the  transit  of  a  vessel 
■n'hich,  being  distributed  to  the  membrana  tympani  from  so  near  and 
large  a  stream,  may,  "with  its  other  plentiful  supply,  account  for  the 
pulsation  which  that  membrane  presents  in  certain  forms  of  disease. 
Behind,  and  winding  round  its  posterior  and  upper  margin,  the  aque- 
duct of  Fallopius  conducts  the  portio  dura  to  the  stylo-mastoid  fora- 
men; and  the  proximity  of  that  nerve  to  the  cavitas  tympani  and  its 
external  partition,  will  enable  us  to  account  for  the  facial  paralysis 
which  frequently  accompanies  disease  of  the  ear. 

The  structure  of  the  membrana  tympani  has  been  carefully  investi- 
gated by  many  eminent  anatomists,  and  is  found  to  consist  of  a  pro- 
per fibrous  layer,  and  two  others  borrowed  from  the  neighboring 
structures, — viz.,  the  epidermis  continuous  with  that  reflected  over 
the  meatus  externally,  and  the  fine,  delicate,  mucous  lining  of  the 
tympanal  cavity — a  portion  of  the  great  gastro-pulmonary  investiture 
prolonged  through  the  Eustachian  tube — internally.  The  tegumen- 
tary  or  external  cuticular  layer  is,  in  a  healthy  condition,  remarkably 
fine,  and  so  transparent  that  the  fibres  of  the  layer  beneath  it  can  be 
seen  distinctly  tkrough  it ;  yet,  in  disease  or  by  decomposition,  it  is 
rendered  white  and  thick,  and  can  frequently  be  detached  in  an  un- 
broken scale.  Within,  the  mucous  lining  is  so  fine  that  it  is  discerned 
with  difficulty,  yet  in  disease  it  becomes  thickened,  vascular,  villous, 
and  even  pulpy. 

The  middle  or  proper  fibrous  layer  is  composed  of  two  laminse, — a 
radiate  externally,  a  circular  internally ;  in  addition  to  which  there  is 
a  cartilaginous  or  ligamentous  ring,  already  referred  to  at  page  211, 
which  is  somewhat  denser  and  whiter  than  the  rest  of  the  membrane, 
and  smTOunds  its  attachment,  except  at  the  upper  portion  where  the 
osseous  groove,  into  which  it  is  inserted,  is  deficient.  This  cartilagi- 
nous circle  is  continuous  with,  and  intimately  united  with  the  perios- 
teum, and  the  radiating  fibres  of  the  external  layer  are  inserted  into 
it.  In  the  li^'ing,  healthy  ear,  it  can  often  be  distinguished  from  the 
rest  of  the  membrane,  but  in  disease  it  becomes  very  manifest,  and 
frequently  presents  a  bright  vascular  zone,  when  the  rest  of  the  mem- 
brane is  unaffected.  It  is  also  the  seat  of  that  inferior  crescentic 
opacity  described  in  the  analysis  of  the  Eegistry,  at  page  141.  The 
fibres  of  the  external  radiating  lamina  proceed  from  the  sides  and  the 
extremity  of  the  malleus  to  the  cartilaginous  ring  for  about  the  infe- 


214  ANATOMY    OF    THE    MEMBRANA    TYMPANI. 

rior  half  of  the  membrane.  Superiorly  the  fibres  pass  across  or  are 
external  to  the  upper  portion  of  the  malleus,  and  are  inserted  into  the 
periosteum  of  the  meatus.  The  circular  lamina  passes,  for  the  most 
part,  behind  the  handle  of  the  malleus,  and  is  united  by  fine  cellular 
tissue  to  the  radiating  layer  in  front  of  it.  It  is  unconnected  with  the 
cartilaginous  ring,  but  is  said  to  be  continuous  with  the  periosteal 
lining  of  the  tympanal  cavity.^ 

Sir  Everard  Home  and  others  maintained  that  the  membrana  tym- 
pani  was  muscular,  but  subsequent  observers  have  not  confirmed  that 
idea ;  and  Professor  Harrison,  in  his  dissection  of  the  ear  of  an  ele- 
phant, that  died  some  years  ago  in  the  Zoological  Gardens,  is  of  opi- 
nion that  the  membrane  is  not  muscular.  Rivinus,  and  some  of  the 
older  anatomists,  conceived  that  a  natural  aperture  existed  in  the 
membrana  tympani,  but  this  error  has  been  corrected  by  modern  in- 
vestigation. That  many  persons  have,  however,  a  perforate  mem- 
brana tympani,  without  experiencing  any  inconvenience  from  it,  is 
well  known ;  such  persons  are  generally  able  to  force  tobacco  smoke 
through"  the  external  meatus.  The  thinnest  portions  of  the  membrane 
are  about  midway  between  the  points  of  the  malleus  downwards  and 
forwards  in  the  anterior  portion,  and  downwards  and  backwards  in 
the  posterior  portion.  It  is,  therefore,  in  one  or  other  of  these  spots 
that  we  generally  find  it  perforated  by  either  accident  or  disease. 

The  membrana  tympani  is,  in  a  state  of  health,  highly  sensi- 
tive, the  slightest  touch  producing  the  most  acute  pain.  Mr. 
Wharton  Jones  says  it  receives  "  a  nerve  from  the  third  division  of 
the  fifth,  which  has  communications  with  filaments  from  the  chorda 
tympani." 

Thin,  dry,  and  almost  transparent  as  the  membrana  tympani  ap- 
pears in  the  healthy  living  state,  it  can,  by  fine  injection,  be  rendered 
a  complete  vascular  network,  and  the  same  appearance  may  be  per- 

^  Mr.  Toynbee,  the  latest  authority  upon  the  subject,  has,  in  an  Appendix  to  his  paper 
"  On  the  Membrana  Tympani  of  the  Human  Ear,"  in  the  Philosophical  Transactions  for 
1851,  described  the  membrana  tympani  as  composed  of  six  lamince, — viz.,  the  epider- 
moid, or  cuticular ;  the  dermoid,  a  distinct  and  complete  lamina  of  membrane  which  is 
continuous  with  the  dermoid  layer  of  the  meatus,  and  which,  from  its  containing  nume- 
rous blood-vessels,  might  be  called  the  vascular  layer ;  the  external  radiating  lamina 
of  the  fibrous  layer,  continuous  with  the  periosteum  of  the  meatus;  the  internal  circular, 
continuous  with  that  of  the  tympanum;  the  mucous  lining;  and  finally  the  epithelium 
covering  that  structure,  in  addition  to  the  circular  fibro-cartilaginous  portion  already  de- 
scribed.    But  these  are  too  minute  subdivisions  for  practical  purposes. 


ANATOMY    OP    THE     MEMBRANA    TYMPANI.  215 

ceived  in  disease,  modified  according  to  tlie  peculiar  structure  or  spe- 
cial vessels  engaged.  Arnold,  in  his  magnifi- 
cent lithographic  plates,  has  given  figures  of  '^' 
the  veins  and  arteries  of  the  memhrana  tym- 
pani,  from  the  latter  of  which  I  have  had  the 
accompanying  accurate  wood-engraving  co- 
pied.^ Soemmerring  has  also  faithfully  re- 
presented the  arteries  of  the  tympanal  mem- 
brane in  the  normal  condition  as  two  long 
vessels  proceeding  from  above  downwards  and 
backwards  along  the  course  of  the  handle  of 
the  hammer,  and  branching  on  either  side  into  the  interior  and  poste- 
rior vibrating  thin  portions  of  the  membrane.  The  outer  circle  in 
the  wood-cut  is  the  bony  ring  upon  the  right  side  seen  from  within  in 
an  infant,  and  the  central  body  is  the  cut  ofi"  extremity  of  the  manu- 
brium. The  large  artery  proceeding  from  above  downwards  is  the 
tympanic  branch  of  the  stylo-mastoid,  which  anastomoses  freely  and 
by  large  trunks  at  the  upper  deficiency  of  the  ring,  with  vessels  re- 
ceived from  the  internal  maxillary  through  the  Glasserian  fissure. 
These  vessels,  uniting,  send  a  considerable  trunk  along  the  attach- 
ment of  the  manubrium ;  but  in  the  living  state,  when  the  membrane 
is  irritated,  two  or  three  vessels  can  generally  be  seen  coursing  down- 
wards on  each  side  of  the  bone,  and  looping  round  its  extremity. 
This  tympanic  artery  then  radiates,  as  shown  in  the  cut,  towards  the 
periphery  of  the  membrane,  where  it  inosculates  so  freely  as  to  form 
a  circumferential  vascular  plexus  with  the  tympanic  branch  of  the 
deep  auricular,  which  is  given  ofi"  at  the  angle  between  the  temporal 
and  internal  maxillary.  This  latter  vessel  reaches  the  membrane  at 
its  lower  curvature,  and  forms  that  crescentic  red  appearance  fre- 
quently seen  in  partial  inflammation  of  the  lower  portion  of  the  mem- 
brana  tympani.  Both  these  vessels  ramify  on  the  external  surface 
of  the  proper  fibrous  layer,  and  being  continuous  with  the  vascular 
supply  of  the  external  meatus  and  the  auricle,  show  how  much  more 
eflFectual  local  depletion  made  round  the  aperture  of  the  auditory  canal 
must  be,  in  relieving  turgescence  of  the  vessels  of  the  membrana 
tympani,  than  when  applied  on  the  mastoid  process,  as  formerly  in 
use.  Towards  the  upper  portion,  in  particular,  we  can  frequently 
trace  those  vessels  which  ramify  about  the  malleus  into  the  vaulted 
roof  of  the  meatus. 

*  TabulsB  AnatomicEe ;   Fasciculus  Secundus;    Tab.  v.  fig.  23.     The  Drawing,  reduced 
about  one-third,  has  been  copied  and  engraved  with  great  fidelity  by  Mr.  Oldham. 


216  ANATOMY    OF    THE    MEMBEANA    TYMPANI. 

That  the  mucous  lining  of  the  tympanic  cavity,  reflected  over  the 
hack  of  the  membrana  tympani,  though  so  thin  and  transparent  in 
health  as  to  be  demonstrated  with  difiiculty,  becomes  in  disease  sud- 
denly and  intensely  vascular,  I  have  had  many  opportunities  of  de- 
termining. In  such  cases,  the  proper  fibrous  layer,  as  'well  as  the 
cuticular  envelope  of  the  membrana  tympani  remain  polished  and  as 
transparent  as  natural,  while  the  inflamed  mucous  lining  may  be  seen 
through  these  structures  of  a  pinkish  color,  somewhat  like  that  observed 
on  the  under  sm-face  of  a  monthly  rose-leaf.  The  arterial  supply  of 
this  lamima  is  obtained  from  a  variety  of  sources,  viz.,  the  stylo-mas- 
toid,  the  temporal,  the  internal  maxillary,  the  meningeal,  and  the  in- 
ternal carotid  arteries  ;  the  latter  sends  its  twig  through  the  small 
hole  in  its  bony  canal,  refered  to  at  page  213.  When  the  proper 
fibrous  membrane  is  inflamed,  it  will  sometimes  present  one  uniform 
sheet  of  bright  red ;  in  addition  to  which  I  have  frequently  seen 
and  pointed  out  to  my  pupils  several  small  straight  vessels  super- 
ficial to  the  general  redness,  and  radiating  from  the  centre  towards 
the  circumference.^ 

During  life  these  vascular  arrangements  can  only  be  seen  in  disease, 
and  with  a  stream  of  clear  bright  sunlight  directed  upon  the  mem- 
brana tympani.  Having  brought  the  membrane  fairly  within  the  field 
of  the  speculum,  a  magnifying  glass  held  in  the  proper  position  will 
not  only,  by  enlarging  the  parts  under  inspection,  but  also  by  concen- 
trating the  light  upon  them,  materially  assist  our  view.  I  lately 
showed,  that  when  the  membrana  tympani  has  been  perforated,  the 
globule  of  air,  or  mucous  bubble,  entangled  in  the  aperture  pulsates 
synchronously  with  the  heart  and  arteries.^  That  this  motion  is  im- 
parted to  the  membrane  by  the  copious  vascular  supply  from  so  many 
large  adjacent  sources,  I  have  had  within  the  last  few  days  an  oppor- 
tunity of  determining  ;  for,  having  placed  a  piece  of  cotton  moistened 
with  oil  within  the  remnant  of  the  membrana  tympani,  which,  except 
at  the  upper  portion,  scarcely  advanced  within  the  tympanic  groove 
of  the  meatus,  I  was  astonished  to  find  that  it  pulsated  in  like  manner 
with  the  membrane,  receiving,  I  presume,  the  impulse  from  the  arte- 

'  In  cases  of  long-continued  inflammation  of  the  iris,  large  red  vessels  can  be  seen 
ramifying  on  its  surface  ;  but,  in  acute  cases,  I  have  lately  been  able  to  determine,  with 
tlie  aid  of  a  strong  magnifying  glass,  that  the  rusty  or  brovirnish-red  unolevated  spots 
seen  on  the  corneal  aspect  of  that  membrane  prove  to  be  nothing  more  than  congeries  of 
vessels  carrying  red  blood. 

^  See  a  case  of  Otorrhoea  with  perforation,  and  description  of  a  new  diagnostic  symp- 
tom, in  the  Medical  Times  and  Gazette  for  27th  M-arcb,  1852,  No.  91. 


MALFORMATIONS    OF    THE    MEMBRANA    TTMPANI.      217 

rial  circle  still  remaining  in  connexion  "n^ith  tlie  groove  to  wliich  tliat 
structure  had  been  originally  attached. 

The  membrana  tympani  is  in  health  the  dr  jest  membrane  in  the 
body, — it  is  hygrometric,  or  capable  of  imbibing  moisture  from  the 
smTOunding  atmosphere,  and  thus  becoming  more  or  less  tense,  ac- 
cording to  the  medium  in  which  it  is  placed  ?  I  believe  it  is,  although 
it  is  difficult  to  offer  proof  thereof.  Certainly  patients  laboring  under 
partial  deafness  affirm,  that  on  dull  moist  days,  or  in  damp  weather, 
they  cannot  hear  so  well  as  when  the  atmosphere  is  dry  and  clear. 
How  much  of  this  depends  upon  the  atmosphere  considered  as  a  me- 
dium for  conducting  sound,  or  upon  the  condition  of  the  membrana 
tympani  itself,  we  have  yet  to  learn.  There  are  other  subjects  con- 
nected with  the  state  of  tension,  amount  of  cm-vature,  and  degree  of 
flattening  or  collapse  which  the  membrane  occasionally  presents,  that 
might  be  considered  here,  but  that  they  properly  belong  to  the  patho- 
logy of  this  part. 

I  have  dwelt  thus  long  upon  the  anatomical  characters  of  the  mem- 
brana tympani  because  it  is  that  part  of  the  ear  least  known  to  stu- 
dents or  practitioners  ;  and  because  in  it  will,  according  to  my  obser- 
vations, be  found  characteristics  of  disease  and  pathological  changes 
from  the  normal  structure,  sufficient  to  account  for  at  least  two-thirds 
of  the  cases  of  impaired  hearing,  independent  of  mechanical  impedi- 
ments from  wax,  and  the  inflammations  presenting  otorrhoea  which 
occur  in  practice.  It  is  true  that  the  pathological  condition  or  amount 
of  disease  seen  upon  the  external  surface  of  the  membrana  tympani 
is  frequently  insufficient  to  account  for  the  degree  of  deafness ;  still 
such  changes,  which  are  ■\dsible  to  the  eye,  are  indicative  of  certain 
conditions  of  the  middle  ear  which  are  beyond  our  ken, — in  the  same 
manner  as  the  state  of  the  cornea  and  iris,  which  we  do  see,  are  cha- 
racteristic of  certain  changes  in  the  parts  beyond  (the  choroid  and  re- 
tina) which  have  proved  destructive  to  \dsion,  which  we  do  not  see ; 
and  the  amount  of  mechanical  defect  is  seldom  commensm'ate  with 
the  extent  of  mischief  in  the  sensient  parts  beyond. 

MALFORMATIONS    OF   THE   MEMBRANA   TYMPANI. 

Where  the  external  auditory  canal  or  the  tympanum  is  deficient,  or 
closed  by  bone,  the  membrana  tympani  must,  as  a  matter  of  course, 
be  wanting.  Cases  have  been  recorded  in  Avhich  a  false  membrane 
covered  the  membrana  tympani.  The  only  instance  I  have  seen  of 
irregularity  in  the  membrana  tympani  consisted  in  malposition  of  the 


218  INJURIES    OF    THE    MEMBRANA    TYMPANI. 

attachment  of  tlie  malleus.  Upon  examining  tlie  ears  of  the  pupils 
in  the  Institution  for  the  Deaf  and  Dumb  at  Claremont,  I  observed 
two  instances  in  which  the  manubrium,  instead  of  occupying  its  usual 
position,  passed  forwards  towards  the  loAver  and  anterior  attachment  of 
the  membrane.  In  a  third,  the  membrana  tympani  was  one  uniform, 
concave  membrane,  without  the  slightest  vestige  of  any  of  the  ossicles 
within  it,  and  I  have  seen  a  similar  case  in  private.  It  is  believed  that 
the  hole  which  Rivinus  considered  as  a  normal  formation  was,  in  the 
instances  which  he  examined,  an  accidental  malformation. 

WOUNDS   AND   INJURIES    OF   THE   MEMBRANA   TYMPANI. 

Injuries  of  the  membrana  tympani,  independent  of  those  arising 
from  inflammation  or  its  consequences,  may  be  caused  by  penetrating 
instrumicnts  or  foreign  bodies  passing  through  from  the  external  mea- 
tus ;  rupture  in  whole  or  in  part  by  external  violence,  such  as  fractm^e 
of  the  temporal  bone,  blows  on  the  side  of  the  head,  or  falls,  &c.  ; 
and  loud  sounds,  concussions,  or  the  sudden  impression  of  a  stream  of 
air  from  "within  the  tympanum,  when  the  membrane  is  in  a  particular 
state  of  tension,  and,  perhaps,  I  should  add,  of  dryness.  I  have 
already  given  instances  of  foreign  bodies  passing  through  the  mem- 
brana tympani ;  and  many  cases  have  been  recorded  of  the  membrane 
having  been  perforated  by  the  accidental  introduction  of  penetrating 
instruments,  or  even  pins  and  ear-pickers.  Sir  Astley  Cooper  relates 
a  case  of  laceration  of  the  membrana  tympani  caused  by  a  box  on  the 
side  of  the  head,  extending  from  above  downwards  across  the  entire 
membrane.  When  bleeding  from  the  ears  occurs  in  hooping- 
cough,  sudden  violent  congestion,  or  strangulation,  I  suppose  the 
hemorrhage  comes  from  the  middle  ear  through  the  burst  membrana 
tympani. 

Case  No.  58  in  the  Registry  is  that  of  a  man  aged  40,  who,  in  a 
fit  of  intoxication,  fell  against  the  street  railing,  and  was  carried  home 
insensible.  He  had  considerable  hemorrhage  from  the  left  ear  both 
at  the  time  and  for  several  hours  after.  Having  lost  the  hearing  com- 
pletely on  that  side,  he  applied  at  the  hospital  one  month  subsequent 
to  the  accident.  The  membrana  tympani  was  rather  opaque,  and  a 
well-marked  cicatrix  running  from  above  downwards,  anterior  to  the 
malleus,  could  be  observed :  it  was  of  a  dense  white  color,  but  became 
red  upon  the  tympanum  being  inflated.  A  second  case,  that  of 
a  female  aged  30,  No.  122  in  Registry,  presented  somewhat  the  same 
appearance  from  a  blow  on  the  right  ear,  followed  by  hemorrhage, 
but  the  accident  had  occurred  three  years  before  I  saw  her.     The  sub- 


INJURIES    OF    THE    MEMBEANA    TYMPANI.  219 

ject  of  hemorrliage  from  the  ear  not  having  been  yet  sufficiently  in- 
vestigated in  a  pathological  or  a  medico-legal  point  of  ^^ew,  a  wide 
field  for  inquiry  into  this  subject  still  exists.  Bleeding  from  the  ear 
has  been  remarked  in  persons  ascending  to  great  elevations,  as  well 
as  in  descending  in  diving-bells ;  and  professional  divers,  likewise,  ex- 
perience the  same  aifection.  Diving  to  any  depth  is  a  frequent  cause 
of  ruptm-e  of  the  membrana  tympani ;  I  have  seen  two  instances  in 
which  it  occmTcd.  A  gentlemen,  when  in  a  warm  bath,  having 
allowed  some  of  the  water  to  get  into  his  external  meatus,  thrust  in 
Ms  finger  forcibly,  with  the  intention  of  dislodging  it,  when  he  felt 
something  burst  in  his  ear,  and  he  immediately  perceived  the  water  in 
his  throat.  I  saw  him  a  short  time  after,  when  the  parts  were  con- 
siderably inflamed.  There  was  a  small  ruptm^e  in  the  inferior  portion 
of  the  membrane.  The  gentleman  was  for  a  long  time  after  the  ac- 
cident in  the  habit  of  applying  a  drop  of  fluid  with  the  point  of  his 
finger  into  the  meatus,  and  letting  it  fall  into  the  aperture  in  the  mem- 
brana tympani, — a  practice  which  many  persons,  with  perforations  in 
the  lower  portions  of  the  membrana,  are  familiar  with.  A  lady,  whose 
ears  I  had  examined  a  few  days  pre"snously,  and  in  whom  the  mem- 
brana tympani  was  remarkably  thin  and  dry,  sent  for  me  to  say  that, 
while  blowing  her  nose  violently,  something  had  suddenly  burst  in  her 
ear.  Upon  inspection,  an  horn-  after  the  accident,  I  found  an  aper- 
tm'e  in  the  anterior  vibrating  portion  of  the  membrane  of  a  trian- 
gular shape,  with  lacerated,  everted  edges ;  a  slight  streak  of  blood 
surrounded  the  rent ;  there  could  be  no  doubt  as  to  the  cause  of  the 
ruptm-e. 

Any  loud,  sharp  report,  such  as  that  from  a  piece  of  artillery,  may 
cause  temporary,  or  even  permanent,  deafness,  rupture  of  the  mem-. 
brana  tympani,  and  hemorrhage  from  the  meatus.  Artillery  recruits 
frequently  sufier  from  bleeding  from  the  ears,  but  the  exact  cause 
has  not  been  yet  fully  ascertained. 

Surgeon  Thornton  of  the  Royal  Artillery,  to  whom  I  addressed  a 
letter  on  the  subject  of  hemorrhage,  tinnitus,  and  deafness  in  gun- 
ners, writes  to  me  as  follows : — "  Many  of  the  men  state  that  they 
have  seen  hemorrhage  occur,  but  it  is  not  so  frequent  as  is  supposed ; 
dulness  of  hearing  is,  however,  very  common,  especially  among  old 
gunners.  The  effect  of  position,  with  reference  to  the  gun,  is  pecu- 
liar,— those  men  who  stand  nearest  the  muzzle  feel  the  report 
most,  but  all  who  are  to  leeward  suffer  more  than  those  to  windward. 
Brass  ordnance  ring  louder  and  make  a  sharper  report  than  iron 
guns, — the  usual  effect  of  which,  as  I  have  myself  experienced,  is 


220  INJURIES    OF    THE    MEMBRANA    TYMPANI. 

that  of  receiving  a  smart  blow  upon  the  tympanum ;  this,  however, 
soon  passes  off,  and  leaves  a  singing  or  tingling  sensation  in  the  ear 
for  two  or  three  days.  Another  peculiar  sensation  is  that  of  having 
water  in  the  ear,  as  if  after  bathing.  After  some  practice  the  ear 
becomes  accustomed  to  the  shock,  and  men  learn  by  experience  where 
to  stand  so  as  to  feel  the  concussion  least." 

In  one  of  the  artillery  now  quartered  in  Dublin,  who  suffered  from 
hemorrhage  from  the  ears  the  first  time  he  was  at  field  practice,  fif- 
teen years  ago,  and  whose  ears  I  examined  this  day,  I  found  a  small, 
white,  well-defined  line  or  cicatrix  proceeding  from  above  downwards 
behind  the  manubrium  of  the  malleus,  than  which  it  is  a  little  shorter. 
Both  ears  presented  precisely  the  same  condition,  and  the  hemor- 
rhage, he  says,  was  equal  upon  each  side.  The  rest  of  the  membrane 
is  normal ;  he  is  not  deaf. 

A  medical  practitioner  at  Portsmouth  has  kindly  afforded  me  the 
following  note  of  his  own  case: — "  I  was  standing  about  half  a  dozen 
yards  from  a  large  cannon  when  it  was  fired  for  a  salute.  At  the 
instant  the  gun  was  fired  I  felt  a  very  severe  shock,  but  unattended 
with  pain,  in  my  right  ear,  which  was  that  nearest  the  canon.  I  im- 
mediately perceived  that  I  had  lost  all  power  over  the  right  side  of 
my  face.  In  fact,  I  had  suddenly  become  affected  with  '  Bell's  pa- 
ralysis.' At  the  end  of  ten  days,  finding  I  did  not  recover,  I  applied 
a  blister  to  the  back  of  my  neck,  lived  sparingly,  and  took  a  sufiicient 
quantity  of  calomel  to  affect  my  gums  slightly.  Not  deriving  the 
benefit  I  anticipated,  I  went  to  London  and  consulted  Sir  B.  Brodie* 
who  recommended  me  to  discontinue  all  treatment  and  to  live  gene- 
rously; when  I  soon  got  quite  well." 

I  was  consulted  by  Captain  H.  some  years  ago,  on  account  of  total 
deafness  of  the  right  ear,  attended  with  an  incessant  buzzing  noise. 
He  stated  that  he  lost  his  hearing  instantaneously  while  grouse-shoot- 
ing. His  gun  had  been  overcharged,  and  "kicked"  so  violently  as 
to  cause  him  to  stagger ;  he  felt  a  sharp  pain  in  his  ear,  and  became 
conscious  of  his  loss  of  hearing  immediately.  The  membrana  tym- 
pani  was  very  much  collapsed. 

I  believe  that  the  best  treatment  which  can  be  adopted  for  recent 
injuries  of  the  membrana  tympani  is  to  let  them  alone,  unless  inflam- 
mation should  arise,  when  it  must  be  met  by  local  depletion,  &c.  It 
is  remarkable  that,  while  we  experience  the  greatest  difficulty  in  keep- 
ing open  a  perforation  made  with  a  surgical  instrument,  accidental 
openings  seldom  close. 


INFLAMMATIONS    OF    THE    MEMBRANA    TYMPANI.    221 
INFLAMMATIONS    OF    THE    MEMBEANA   TYMPANI. 

Myringitis,  or  inflammation  of  the  membrana  tympani,  has  not 
been  recognised  or  described  by  authors  until  within  the  last  few 
years :  and  its  varieties,  with  their  peculiar  symptoms,  are  by  no 
means  accurately  understood.  Itard,  one  of  the  earliest  and  most 
esteemed  writers  upon  aural  surgery,  has  not  mentioned  it,  though  the 
symptoms  of  at  least  one  form  of  the  disease  are  enumerated  by  him 
under  the  head  of  internal  otitis.  The  old  divisions  of  inflammations 
of  the  ear  into  otitis  externa  and  interna  do  not  in  any  way  assist 
either  our  diagnosis  or  improve  our  treatment,  and  the  same  may  be 
said  of  the  divisions  into  acute  and  chronic.  The  otorrhoea  which 
follows  in  such  cases,  and  which  formed,  with  many  writers,  grounds 
for  nosological  arrangement,  being  but  a  symptom,  like  that  of  leu- 
corrhoea  in  the  female,  is  an  insufficient  ground  of  diagnosis. 

Lincke,  as  already  shown  at  page  148,  classes  the  aural  inflamma- 
tions according  to  their  causes,  as  the  erysipelatous,  scrofulous,  syphi- 
litic, &c. ;  but  the  exact  locality  or  seat  of  the  original  inflammation, 
or  the  peculiar  appearance  of  such,  are  not  specified.  These  are 
merely  enumerations  of  diseased  actions,  generally  characterized  by 
muco-purulent  discharge,  attendant  on,  or  following  these  different 
affections.  He  was,  however,  one  of  the  first  accurate  describers  of 
the  "  Entziindung  des  Trominelfells,"  the  true  Myringitis.^ 

Kramer,  in  his  first  work,  gave  a  section  on  acute  inflammation  of 
the  membrana  tympani,  but  upon  a  careful  perusal  of  it  we  find  about 
four  pages  devoted  to  the  description  of  that  disease,  while  the  re- 
mainder is  occupied  with  the  consideration  of  polypus,  and  a  detail  of 
the  various  methods  recommended  for  performing  perforation. 

Mr.  Pilcher  disposes  of  inflammation  of  the  membrana  tympani  in 
a  few  pages,  but  enumerates  most  of  the  symptoms  of  the  affection 
(except  the  minute  appearances  of  the  membrane),  under  the  head  of 
otitis  interna.  Mr.  T.  W.  Jones  has  given  a  short  description  of  one 
form  of  the  disease.  I  cannot,  however,  agree  with  him,  that  in 
"  otitis  interna  morbid  changes  in  the  membrana  tympani  occur  only 
when  it  is  threatened  with  bursting  by  the  matter  accumulated  in  the 
cavity  of  the  tympanum,  and  has  also  become  involved  in  the  inflam- 
matory action."  On  the  contrary,  my  experience  leads  me  to  believe 
that  inflammation  of  the  middle  ear  always,  and  at  the  very  com- 
mencement, is  shown  by  the  appearance  of  the  membrana  tympani ; 
and  this  observation  must  remain  undisputed  until  a  sufficient  number 

'  From  myringa — myrinx, — the  memljrane  of  the  drum. 


222      INFLAMMATIONS    OF    THE    MEMBEANA    TYMPANI. 

of  accurate  examinations  shall  have  been  made  in  the  commencement 
of  cases  of  otitis  interna,  to  negative  it.  It  is  quite  plain  from  Dr. 
Williams's  account  of  the  "  inflammation  and  ulceration  of  this  mem- 
brane," that  he  never  examined  the  membrane  in  this  condition; 
indeed,  I  doubt  if  he  ever  saw  the  disease  under  consideration. 

Dr.  Martell  Frank  has  given  a  concise  but  faithful  description  of 
both  the  acute  and  chronic  form  of  the  disease.  M.  Hubert-Valle- 
roux  does  not  even  enumerate  the  inflammation  of  the  membrana 
tympani  in  his  catalogue  of  aural  diseases ;  and  Schmalz  has  done 
little  more  than  glance  at  the  disease.  He  has  evidently  mixed  up 
the  description  of  its  symptoms  with  those  of  other  inflammatory 
affections  of  the  ear. 

In  the  following  cases  and  description,  the  inflammations  of  the 
membrana  tympani  have,  in  many  instances,  been  connected  with 
those  of  the  middle  ear,  because  I  do  not  believe  it  possible  for  one 
to  exist  independent  of  the  other  for  any  length  of  time :  no  more 
than  an  ophthalmia  can  be  circumscribed,  or  than  we  can  by  the  term 
iritis  define  a  simple  uncomplicated  inflammation  of  the  membranous 
diajDhragm  of  the  ocular  chamber. 

By  the  term  myringitis  the  reader  is  to  understand  inflammation 
of  the  membrana  tympani ;  and  by  tympanitis,  inflammation  of  the 
cavity  of  the  tympanum. 

Ah.scess  in  the  memhrana  tympani  must  be  a  very  rare  disease.  In 
the  year  1843  I  had  opportunities  of  seeing  two  cases  of  a  circum- 
scribed deposit  of  pus  between  the  layers  of  the  membrane ;  each 
was  about  the  size  of  No.  6  shot ;  and  in  one  instance,  when  I  punc- 
tured the  abscess  Avith  a  cataract  needle,  a  small  drop  of  pus  oozed  out. 

I  have,  in  the  nosological  chart  at  page  152,  enumerated  the  various 
inflammations  to  v/hich  the  membrana  tympani  is  liable,  but  for  all 
practical  purposes  the  following  forms,  with  which  I  am  myself 
familiar,  will  suffice  : — 

1.  Acute  inflammation  of  the  membrana  tympani,  commencing  in 
the  fibrous  layer,  accompanied  by  inflammation  of  the  cavity  of  the 
tympanum  ;  frequently  of  a  rheumatic  character.^ 

'  This  enumeration,  but  somewhat  differently  arranged,  is  that  which  I  adopted  in 
my  Essay  upon  "  Inflammatory  Affections  of  the  Membrana  Tympani  and  Middle  Ear," 
published  in  1848,  and  I  have  not  since  seen  reason  to  alter  it  or  render  it  more  minute. 
In  Mr.  Harvey's  book  upon  "  Rheumatism,  Gout,  and  Neuralgia,"  &c.,  of  the  Ear,  he 
states  in  the  opening  paragraph,  that,  "  Rheumatism  affecting  the  structures  of  the  ear 
has  not  hitherto,  as  far  as  my  researches  have  enabled  me  to  ascertain  the  fact,  been 
noticed  in  any  medical  work."     Now,  both  Lincke  and  Frank  have  given  descriptions 


ACUTE    MYRINGITIS.  223 

2.  Subacute  inflammation,  unaccompanied  by  pain. 

3.  Sypliilitic  inflammation. 

4.  Strumous  inflammation,  generally  in  the  mucous  layer,  with 
mucous  engorgement  of  the  tympanum. 

5.  Chronic  inflammation,  with  or  without  inflammation  of  the  ca- 
vity of  the  tympanum. 

6.  Febrile  inflammations,  accompanying  the  exanthematic  and  other 
fevers,  extending  from  the  tympanum,  aud  generally  producing 
otorrhoea. 

ACUTE    MYRINGITIS. 

In  acute  inflam7nation  of  the  memhrana  tympani,  the  vascularity 
is  generally  seated  in  the  true  fibrous  structure,  and  is  usually  the 
result  of  cold,  and  often  attributed  to  rheumatic  diathesis,  sudden  ex- 
posure to  a  low  temperature,  blasts  of  harsh  cold  wind,  diving  in  the 
sea,  foreign  bodies,  and  irritating  substances  introduced  into  the  ex- 
ternal ear,  &c.  The  auditory  canal,  and  sometimes  even  the  auricle, 
is  engaged ;  and  although  we  are  not  able  to  observe  the  precise  pa- 
thological condition  of  the  cavity  of  the  middle  ear,  or  its  investing 
membrane,  there  can  be  little  doubt  but  these  parts,  sooner  or  later, 
participate  in  the  general  inflammatory  action.  As,  however,  we  de- 
nominate that  form  of  internal  ophthalmia  which  chiefly  or  primarily 
attacks  the  iris,  an  ii'itis,  although,  in  the  severer  kinds  of  that  afi"ec- 
tion,  several  if  not  all,  the  other  textures  of  the  eye  eventually  be- 
come engaged,  so  in  inflammations  of  the  membrana  tympani,  to 
which  the  term  myringitis  is  applicable,  we  must  expect  that  sooner 
or  later  the  adjoining  structures, — the  mucous  membrane  lining  the 
tympanum,  with  its  numerous  nerves,  the  nerves  which  cross  this  ca- 
vity, the  periosteum,  the  mastoid  cells,  the  investitures  of  the  Eusta- 
chian tube,  the  membrane  of  the  fenestra  cochleae,  the  muscles,  liga- 
ments, and  other  connexions  of  the  ossicula,  the  labyrinth,  the  internal 
ear,  and  the  auditory  nerve  itself, — will  sooner  or  later  participate  in 
the  unhealthy  action  going  forward;  and  which  must,  either  directly 
by  the  inflammatory  lesion,  or  its  subsequent  efi"ects,  serve  to  impair 
hearing,  and  cause  organic  changes  in  this  delicate  organ.  But  in 
addition  to  the  alterations  analogous  to  those  which  occur  in  ophthal- 
mic inflammations,  we  may  -have,  from  the  peculiar  anatomical  struc- 
ture of  the  ear,  an  extension  of  disease  to  parts  which  not  only  de- 

of  gouty  and  rheumatic  otitis ;  and  Mr.  Harvey  has  quoted  at  length  a  -well-marked  in- 
stance of  "  severe  rheumatic  inflammation  of  the  membrane  and  cavity  of  the  tympa- 
num," from  my  Essay  already  alluded  to. 


224  ACUTE    MYRINGITIS. 

stroy  the  sense  of  hearing,  but  prove  dangerous  to  life,  as  when  the 
bone,  the  membranes  of  the  brain,  or  the  encephalon  itself,  become 
engaged. 

The  dermal  structure  partakes  of  the  abnormal  action,  and,  together 
with  that  of  the  auditory  canal,  pours  out  a  muco-purulent  secretion, 
or  even  pus  itself, — is  occasionally  raised  into  vesicles,  becomes  the 
seat  of  pustules,  ulcerates,  throws  out  granulations,  and  becomes 
thickened,  &c.,  dm'ing  the  progress  of  disease.  The  true  fibrous 
membrane  passes  through  all  the  pathological  changes  to  which  such 
structures  are  liable  from  inflammatory  action  or  its  results ;  and 
although  the  precise  anatomical  condition  of  the  two  may  not  be  ana- 
logous, yet  the  diseases  of  the  cornea  and  of  the  membrana  tympani 
bear  a  remarkable  analogy,  particularly  in  the  subsequent  appearances 
of  vascularity,  thickening,  opacity,  and  morbid  deposits,  &c.,  which 
they  present,  together  with  adhesions  by  bands  of  membrane  to  the 
parts  within  the  chambers,  to  which  they  form  the  external  boundaries. 

The  following  are  generally  the  order  of  symptoms.  A  seizure  of 
sudden  and  intense  pain  in  the  ear  itself,  most  generally  first  appear- 
ing at  night,  and  attended  with  nocturnal  exacerbations  during  the 
progress  of  the  disease.  This  pain  is  of  a  most  excruciating  kind, 
producing  at  times  delirium,  and  is  usually  likened  to  that  of  a  sharp 
instrument  penetrating  through  the  ear  to  the  brain :  it  is,  especially 
when  the  cavity  of  the  tympanum  is  engaged,  increased  by  coughing, 
sneezing,  blowing  the  nose,  chewing,  or  swallowing,  or  by  pressing 
upon  the  tragus,  particularly  when  the  jaw  is  open.  The  beating  of 
the  carotid  is  distinctly  felt  in  the  ear,  and  each  throb  of  the  artery, 
especially  if  the  circulation  be  excited,  increases  the  suffering ;  and 
there  is  frequently  a  feeling  of  fulness  and  bursting  within  the  organ. 
With  this  there  is  also  pain  and  soreness  over  the  side  of  the  head,  in 
the  teeth,  in  the  eye  and  temple,  and  in  the  superior  lateral  triangle 
of  the  neck ;  with  occasionally  stifihess  and  soreness  of  the  upper 
portion  of  the  mastoid  muscle,  and  often  flying  rheumatic  pains 
throughout  the  body,  particularly  in  middle-aged  persons,  and  those 
who  have  previously  suffered  from  rheumatic  attacks.  If  neglected, 
or  unrelieved  by  treatment,  the  pain  extends  to  the  throat  and  mas- 
toid region,  and  is  increased  on  pressing  the  mouth  of  the  Eustachian 
tube  with  the  finger.  The  severity  of  the  pain  experienced,  and  the 
extent  of  soreness  to  the  touch,  is  to  a  certain  degree  a  test  of  the 
amount  of  the  inflammation ;  and  the  peculiarity  of  the  pain  is  also  a 
means  of  judging  of  the  seat  of  the  inflammation ;  for  if  it  is  expe- 


ACUTE    MYRINGHTIS.  225 

riencecl  in  swallowing,  mastication,  or  sneezing,  &c.,  we  may  presume 
that  the  inflammation  has  extended  over  the  middle  ear. 

I  have  known  a  man  to  be  treated  for  inflammation  of  the  brain 
who  merely  labored  under  inflammation  of  the  ear ;  and  on  the  other 
hand  a  very  cm-ious  impression  exists  among,  and  is  too  frequently 
acted  on  by,  the  profession,  that  earache  is  a  neuralgic  afl"ection. 
To  this  very  general  mistake  must  we  attribute  the  practice,  so  fre- 
quently and  empirically  resorted  to,  of  pouring  into  the  ear  the  various 
nostrums — sedatives,  and  stimulants,  calculated  to  allay  pain  in  ex- 
ternal parts.  So  rare  is  true  nera-algia  of  the  ear,  that  Dr.  Kramer 
says,  he  "never  observed  earache  without  evidence  of  inflammation 
either  of  the  meatus  or  of  the  membrana  tympani."  Although  I  am 
not  prepared  to  go  to  the  length  of  saying  that  such  an  affection  does 
not  occasionally  exist,  I  must  say  that  I  cannot  tax  my  memory  with 
more  than  one  or  two  instances  of  so-called  "  nervous  otalgia,"  for 
which  I  have  been  consulted,  that  upon  a  careful  examination  I  could 
not  discover  some  dii'ect  visible  cause  for  it :  and  I  must,  therefore, 
with  Dr.  Kramer,  "  deny  to  those  persons  the  right  of  pronouncing  a 
decisive  opinion  on  the  existence  of  a  nervous  otalgia,  who  do  not 
understand  investigating  the  membrana  tympani  in  bright  sunshine, 
and  with  the  aid  of  the  speculum,  and  who  are  not  in  the  habit  of 
doing  it." 

Usually  coincident  with  the  seizure  of  pain,  the  patient  complains 
of  tinnitus  aurium,  and  the  noises  are  described  as  a  dull  throbbing, 
or  pulsation, — a  loud  pumping  like  that  of  a  steam-engine, — with 
the  occasional  supervention  of  a  sound  varying  in  loudness  and  inten- 
sity from  the  ticking  of  a  watch  to  the  striking  of  a  loud  clock ;  but 
the  most  usual  simile  given  by  patients  in  describing  those  ear-noises 
is  that  tidal  sound  perceived  on  holding  a  conch-shell  to  the  ear.  In 
the  severer  forms  of  aural  inflammation,  patients  very  frequently 
liken  this  unpleasant  symptom  to  the  falKng  of  water,  the  dashing 
of  a  cataract,  or  that  peculiar  rushing  sound  produced  by  the  sudden 
escape  of  water  through  a  large  pipe  or  sluice-gate.  In  the  more 
mitigated  forms,  and  the  more  advanced  and  chronic  stages,  we 
generally  find  the  sounds  of  a  hissing  or  blowing  character,  and 
usually  likened  to  the  singing  of  a  kettle,  the  noise  of  a  distant  storm, 
the  fluttering  of  the  leaves  of  trees,  the  chirping  of  birds,  the  distant 
ringing  of  bells,  a  dull  cooing  in  the  ear,  musical  sounds  of  various 
kinds,  the  buzzing  of  bees,  blowing  of  bellows,  whistling,  and  other 
noises  of  a  similar  character,  to  which  I  have  already  referred  at 

15 


226  ACUTE    MYEINGITIS. 

page  90.  Any  increase  of  the  circulation,  or  nervous  excitement  of 
any  kind,  particularly  in  irritable  patients,  invariably  makes  these 
ear-noises  worse. 

Deafness — consisting  either  of  impaired  hearing  or  total  loss  of 
that  sense  on  the  affected  side — comes  on  contemporaneously  with  the 
pain,  or  succeeds  it  in  a  few  hours  after ;  if,  however,  but  one  side 
has  been  attacked,  the  patient  is  not  at  first  conscious  of  his  loss  of 
hearing.  In  some  rare  cases  there  is  for  a  short  time  during  the 
progress  of  tympanal  inflammation  an  exaltation  of  the  sense  of 
hearing,  in  which  (like  photophobia  in  ophthalmia)  all  sounds  become 
intolerable. 

In  severe  inflammations  of  the  ear,  pain  in  the  teeth  of  the  affected 
side  is  no  uncommon  accompaniment ;  and  pain  from  toothache,  with 
or  without  decay  in  the  last  molar,  is  often  referred  to  the  ear.  We 
should,  therefore,  carefully  distinguish  between  these  two  causes.  I 
think  dentists  too  frequently,  and  without  examining  the  state  of  the 
meatus,  tell  patients  laboring  under  earache  to  "wait  until  the  teeth 
are  set»  right."  In  cases  of  chronic  earache,  the  state  of  the  last 
molar  tooth  should  always  be  examined. 

To  these  local  subjective  symptoms  may  be  added  the  following 
constitutional  ones :  coryza,  sneezing,  coughing,  and  other  symptoms 
of  catarrh,  increased  heat  of  skin,  headache  with  a  feeling  of  weight 
in  the  head,  and  sometimes  well-marked  hemicrania ;  there  is  always 
great  distress  and  anxiety  of  countenance  ;  sleeplessness,  restlessness, 
nocturnal  exacerbations,  the  acute  pain  coming  on  at  a  particular 
hour ;  quickness  of  pulse,  occasional  rigors,  in  some  instances  delirium, 
and  even,  in  very  bad  cases,  all  the  symptoms  of  cerebral  disease,  of 
which  the  case  at  page  234  is  an  example.  The  digestive  organs  are 
seldom  much  engaged  in  the  progress  of  the  disease ;  the  urine 
becomes  high-colored,  and,  towards  the  termination  of  the  acute  symp- 
toms, deposits  a  copious  pinkish  sediment.  The  circulation,  except  in 
very  severe  cases,  is  seldom  much  affected. 

The  physical  signs  consist,  in  the  severe  cases,  of  heat,  pain,  and 
slight  erysipelatous  redness  of  the  auricle :  in  very  aggravated  cases, 
— heat,  fulness,  and  oedema,  as  well  as  pain  over  the  mastoid  region, 
and  great  soreness  of  the  scalp  on  the  affected  side.  In  ordinary 
cases  there  is  slight  tumefaction  of  thelining  of  the  external  meatus  ; 
complete  cessation  of  the  cerumenous  secretion ;  a  bright  pinkish 
color :  a  swelling  and  polish  of  the  lining  of  the  auditory  canal,  which 
is  streaked  with  long  tortuous  vessels,  accompanied  by  heat  and  itch- 
ing of  that  part,  and  all  the  symptoms  of  inflammation  described  at 


ACUTE    MYRINGITIS.  227 

page  194.  The  membrana  tympani  first  loses  its  polish,  then  its  semi- 
transparency, — becomes  in  the  early  stages,  and  in  very  mild  cases, 
of  a  dull  yellow,  but  this  is  variable  and  seldom  seen ;  the  most  usual 
color  varies  through  all  the  shades  of  red,  from  a  slight  pinkish  hue 
to  that  of  a  dark  damask  rose  tint,  and  is  caused  by  the  different 
degrees  of  vascularity  produced  by  the  greater  or  less  intensity  of 
the  inflammation,  the  structures  engaged,  and  the  medium  through 
which  we  see  the  vessels.  In  addition  to  the  vascular  arrangement 
figured  and  described  at  page  215,  new  vessels  seem  during  inflamma- 
tory action,  like  as  in  the  coats  of  the  eye,  to  start  into  existence, 
and  to  branch  and  inosculate  till  the  whole  seems  one  mass  of  bright 
livid  red.  Generally  speaking,  the  upper  portion  around  the  attach- 
ment of  the  head  of  the  malleus  is  the  first  to  become  vascular,  the 
last  to  regain  the  natural  hue,  and  the  part  in  which  the  color  becomes 
deepest.  The  vessels  alongside  the  handle  of  that  bone  are  always 
well  marked,  though  the  line  of  its  attachment  remains  for  some  time 
whitish,  owing  to  the  intimate  connexion  of  the  membrane  to  it  at 
this  part.  Around  the  cu'cumferential  ligamentous  ring,  particularly 
at  its  lower  and  anterior  part,  an  areola  of  short  vessels  form  a  cres- 
cent of  almost  a  line  in  breadth ;  they  all  run  towards  the  centre,  and, 
when  well  marked,  look  like  the  zone  seen  in  iritis,  or  that  observed 
in  the  edge  of  the  cornea  in  the  commencement  of  corneitis,  to  which 
disease  the  appearances  seen  in  myringitis  bear  a  great  resemblance. 
It  is  only  in  the  early  stage,  or  when  the  redness  is  disappearing,  that 
this  peculiar  peripheral  vascularity  is  well  marked.  With  this  general 
redness  may,  in  some  cases,  be  seen  well-defined  patches  of  ecchymosis, 
generally  on  the  anterior  vibrating  portion ;  but  as  the  vascularity 
increases,  even  the  exact  position  of  the  manubrium  cannot  be  recog- 
nised,— all  is  one  red  mass.  The  membrane  also  becomes  swollen, 
and  its  surface  apparently  villous ;  rarely  vesicles,  and  still  more 
rarely  pustules,  form  on  its  sm-face.  Ulcers  occasionally  form  upon 
it ;  these  usually  occupy  the  anterior  part  of  the  lower  vibrating 
portion,  but  I  have  occasionally  seen  them  situated  posteriorly.  It 
is  possible  that  they  may  have  commenced  as  vesicles  or  pustules,  but 
we  require  more  extended  and  minute  observations  to  determine  this 
point. 

Exudation  of  lymph  and  muco-purulent  secretion,  with  detachment 
of  the  cuticle,  both  from  the  surface  of  the  membrane  and  the  parie- 
tes  of  the  canal,  follow.  Lymph  is  very  frequently  effused  in  the  sub- 
stance or  between  the  lamina  of  its  proper  fibrous  tunic,  and  there 


228  ACUTE    MYRINGITIS. 

can  be  little  doubt  that,  in  the  severe  forms  of  the  disease,  this  mor- 
bid product  is  poured  out  in  large  quantity  upon  the  surface  of  the 
tympanum,  the  membrane  of  wliich  must  partake  largely  of  the  inflam- 
matory action  so  visible  in  the  external  septum.  That  these  lymphy 
exudations — both  by  thickening  the  tympanal  membrane  itself,  and  by 
acting  in  a  similar  manner  upon  the  lining  of  the  cavity  of  the  tym- 
panum and  the  parts  contained  within  it,  by  bands  of  adhesion  within  its 
walls,  thus  drawing  inward  and  arresting  the  vibrations  of  the  membrana 
tympani,  cm^tailing  the  motion  of  the  ossicula,  injuriously  affecting  the 
membrane  of  the  fenestra,  and  particularly  by  impairing  the  functions 
of  those  tympanic  branches  of  the  glosso-pharyngeal  nerve  which 
ramify  on  the  mucous  membrane — are  the  principal  causes  of  deafness, 
I  have  little  doubt.  Perforation  of  the  tympanal  membrane,  either 
by  rupture,  abscess,  slough,  or  ulceration ;  but  which  it  is  not  always 
easy  to  determine,  also  occurs  occasionally.  When  rupture  takes 
place,  and  that  accumulations  of  blood,  mucus,  or  pm-ulent  matter, 
pent  up  within  the  tympanum,  are  evacuated,  relief  is  generally  ex- 
perienced. In  this  condition — with  the  cavity  of  the  tympanum  open, 
polypoid  growths  occurring  in  the  meatus,  and  granulating  over  the 
surface  of  the  tympanum,  and  a  copious  and  very  often  fetid  discharge 
pouring  both  from  the  auditory  passage  and  the  drum — the  case  be- 
comes one  of  otorrhoea,  the  peculiar  symptoms  and  management  of 
which  are  detailed  in  the  chapter  on  that  subject. 

In  cases  where  neither  rupture  nor  ulceration  has  taken  place,  as 
the  disease  advances,  the  vascularity  of  the  membrana  tympani  de- 
creases, first  in  the  centre  of  its  vibrating  portion,  then  around  its  cir- 
cumference, and  finally  along  the  mallear  attachment.  The  membrane 
assumes  a  muddy,  yellowish,  opaque  color ;  after  this  clears  ofi"  we 
find  it  opaque  throughout,  or  in  spots ;  sometimes  these  opacities  can 
be  plainly  discovered  upon  the  interior  of  the  membrane,  like  the 
speckled  opacities  seen  upon  the  membrane  of  the  aqueous  humor. 
In  other  cases,  the  result  of  the  inflammation  is  seen  in  the  uniform 
grayish-white  opacity,  similar  to  leucoma  of  the  cornea ;  and  in  time, 
as  the  superficial  polish  is  restored,  the  membrane  presents  a  pearly 
aspect  very  different  from  the  semitransparent  character  of  the  healthy 
condition. 

A  not  uncommon  eff"ect  of  inflammation  of  the  tympanum  and  its 
membranes,  particularly  when  allowed  to  run  its  course  unchecked  is, 
collapse  on  a  drawing  inward  of  the  membrana  tympani,  as  explained 
at  page  143.     In  such  cases  the  handle  of  the  hammer  forms  the  most 


ACUTE    MYRINGITIS.  229 

projecting  point  seen  at  the  bottom  of  the  auditory  canal ;  and  the 
anterior  and  posterior  divisions  of  the  membrane  can  be  distinctly  ob- 
served forming  deeply  curved  folds  upon  either  side  of  it. 

The  inflammatory  process  must,  in  severe  [cases,  also  extend  into 
the  mastoid  cells ;  the  periosteum  lining  the  bony  portion  of  the  audi- 
tory canal  will  in  time  become  engaged,  as  well  as  the  pericranium 
over  the  mastoid  process,  and  post-aural  region  of  the  skull,  and  pre- 
sent the  symptoms  already  described.  If  allowed  to  proceed  unchecked 
by  the  efforts  of  natm'e  or  by  art,  the  death  of  the  bone  beneath  will 
follow ;  while  in  cases  still  more  severe,  the  entire  petrous  portion  of 
the  temporal  bone  will  become  inflamed, — the  dura  mater  will  sepa- 
rate from  it, — pm-ulent  deposit  takes  place  in  the  cavity  thus  produced, 
— the  brain,  as  well  as  its  investments  opposite  those  portions,  will 
partake  of  the  inflammation, — and  death  follow,  either  from  abscess, 
or  diffuse  inflammation  of  the  cerebrum  or  cerebellum. 

In  some  rare  cases,  paralysis  of  the  muscles  of  the  face,  on  the  af- 
fected side,  presenting  all  the  peculiar  phenomena  of  that  disease,  is 
produced ;  instances  of  which  will  be  related  hereafter. 

During  the  progress  of  the  inflammatory  action  in  the  tympanum 
and  its  external  membrane,  the  throat,^in  some  cases,  becomes  engaged, 
its  mucous  membrane  presenting  a  copperish-red  appearance,  and 
becoming  swollen  and  infiltrated.  The  tonsils  are  also  swollen ;  there 
is  some  difficulty  of  deglutition ;  and  if  an  examination  of  the  pharyn- 
geal extremity  of  the  Eustachian  tube  be  made  with  the  finger,  ac- 
cording to  the  method  described  at  page  88,  considerable  pain  is  ex- 
perienced in  the  track  of  the  tube,  as  well  as  in  the  middle  ear. 
There  can  be  little  doubt  of  the  inflammatory  condition  of  the  middle 
ear,  extending  over  the  Eustachian  tube,  and  causing  such  thickening 
and  obstruction  of  its  lining  membrane,  with,  perhaps,  an  accumula- 
tion of  mucus,  as  greatly  impedes  the  transit  of  air  into  the  drum, 
and  causes  that  peculiar  feeling  of  stuffing,  and  occasional  sudden 
bursting  in  the  middle  ear,  of  which  we  are  all  conscious  when  labor- 
ing under  influenza  or  catarrh. 

The  nose  sometimes  partakes  in  the  unhealthy  condition  of  the 
neighboring  mucous  membrane,  and  a  feeling  of  stuffing  in  that  part, 
together  with  much  faucial  respiration,  is  not  an  uncommon  attendant 
upon  acute  inflammation  of  the  middle  ear  and  mem^brana  tympani. 

This  form  of  inflammation  chiefly  attacks  the  young  and  middle- 
aged  ;  one  ear  is  much  more  frequently  affected  than  both ;  the  light- 
haired  and  fair-complexioned  are  more  liable  to  it  than  the  dark.     So 


230  ACUTE    MYRINGITIS. 

much  more  frequent  are  its  attacks  in  spring  than  at  any  other  period 
of  the  year,  that  it  sometimes  seems  to  be  epidemic  at  that  time. 
The  duration  of  the  disease  varies  from  six  to  fourteen  days,  but  may 
last  a  month,  and  its  effects  several  months. 

In  the  foregoing  description  it  was  impossible  to  avoid  details  and 
symptoms  common  to  inflammation  of  the  cavitas  tympani — true  otitis 
— and  its  membranous  partition,  because  the  diseased  action  sooner  or 
later  extends  from  the  one  to  the  other. 

With  respect  to  treatment,  the  temperature  in  cases  of  acute  myrin- 
gitis should  be  strictly  attended  to :  the  patient  should,  if  possible, 
be  confined  to  a  warm,  well-ventilated  apartment,  or,  if  obliged  to  go 
abroad,  the  cold  air  should  be  carefully  excluded  from  the  ear ;  but  in 
the  severe  form  of  the  disease  it  is  absolutely  necessary  to  confine  the 
patient  to  bed. 

I  have  never  had  occasion  to  employ  general  bleeding ;  but  local 
depletion,  either  by  means  of  cupping  or  leeches,  is  invariably  neces- 
sary ;  and  leeches  are  not  only  the  most  effectual  and  easiest  mode  of 
abstracting  blood,  but  they  can  be  applied  nearest  the  seat  of  disease, 
and  repeated  as  frequently  as  necessary.  To  be  effective  they  must 
be  applied  according  to  the  directions  which  I  have  given  at  page  93, 
to  which  I  would  here  particularly  direct  the  attention  of  the  reader. 
The  auditory  canal  having  been  filled  with  cotton  wool,  to  jDrevent 
them  going  in  too  far,^  and  the  blood  from  flowing  into  it,  five  or  six 
leeches  should  be  attached  round  the  external  meatus,  the  direct  vas- 
cular communication  of  which  Avith  the  membrana  tympani  I  have 
already  pointed  out  at  page  215.  If  allowed  to  scatter  over  the  con- 
cha, they  will  not  afford  the  same  amount  of  relief :  but  several  may 
be  applied  in  front  of  the  tragus,  and  others,  if  necessary,  close  into 
the  angle  between  the  auricle  and  the  mastoid  process.  The  bleeding 
should  be  encouraged  by  warm  applications,  stupes,  and  poultices,  and, 

'  I  knew  one  instance  in  which,  from  the  omission  of  the  cotton  a  leech  attached  itself 

somewhere  within  tlie  meatus,  and 
^^    '■  caused   the  ^  most    excruciating    agony. 

AUhough  I  generally  mark  the  places  to 
which  the  leeches  should  be  attached 
with  spots  of  ink,  I  have  frequently  the 
mortification  of  finding  that  they  have 
been  allowed  to  attach  themselves  to 
places  far  remote  from  the  edge  of  the 

meatus.     The  apothecary  should  bring  with  him  a  large  quantity  of  leeches,  and  employ 

the  glass  here  figured  of  the  natural  size. 


ACUTE    MYRINGITIS.  231 

if  necessary,  kept  tip  by  relays  of  leeches  for  eight  or  twelve  hours 
together.  The  relief  afforded  by  leeches  in  this  disease  is  often  instan- 
taneous, and  is  always  most  marked. 

The  employment  of  moist  heat,  as  directed  at  page  97,  will  always 
afford  relief.  In  addition  I  may  mention,  that  applying  the  tube  at- 
tached to  a  Mudge's  inhaler  to  the  external  auditory  passage,  and 
allowing  the  warm  vapor  to  have  access  to  the  inflamed  parts,  will 
give  the  patient  great  comfort. 

When  there  is  much  external  neuralgic  pain,  or  rheumatic  sore- 
ness and  tenderness  to  the  touch  about  the  external  ear,  and  over  the 
side  of  the  head  and  face,  relief  will  be  experienced  from  the  various 
sedative  applications,  of  which  I  may  mention  three, — tinctiu'e  of 
aconite,  chloroform,  and  the  belladonna  with  compound  camphor  lini- 
ment. There  are  two  popular  remedies  for  "  a  pain  in  the  ear  "  still 
in  very  general  use, — the  application  of  a  roasted  fig,  and  the  inser- 
tion into  the  meatus  of  a  hot  roast  onion  or  a  clove  of  garlic.  The 
former  is  innocuous,  the  latter  is  by  no  means  harmless.  The  em- 
pirical practice  of  pouring  laudanum  and  oil  into  the  ear  the  moment 
the  pain  is  complained  of,  employed  by  the  profession,  is,  I  trust,  on- 
the  wane. 

The  bowels  should  in  this,  as  in  all  other  febrile  diseases,  be  opened, 
but  the  conditi-on  of  the  digestive  organs  does  not  appear  to  influence 
the  inflammatory  affections  of  the  ear  as  much  as  they  do  those  of 
the  eye.  The  state  of  the  skin,  however,  which  is  generally  hot  and 
dry,  requires  our  more  especial  attention;  and  sudorifics  are,  in  the 
early  stage  of  the  disease,  decidedly  indicated.  Having  leeched, 
fomented,  and  purged,  James's  powder,  combined  with  small  doses  of 
blue  pill  and  henbane,  will  be  found  very  efiicacious.  Abstinence 
from  animal  food,  and  the  use  of  the  footbath,  together  with  all  such 
means  as  are  calculated  to  allay  inflammation  and  febrile  excitement, 
should  be  had  recourse  to. 

Counter-irritation,  by  means  of  small  blisters  applied  upon  the 
bald  space  behind  the  am-icle,  and  below  the  lobe,  are  advantageoixs 
in  the  more  advanced  stage  of  the  disease,  and  after  local  depletion 
has  been  fully  employed.  Generally  speaking,  blisters  are  too  much 
relied  upon,  or  applied  too  early  in  the  disease ;  but  as  it  advances 
they  will  be  found  highly  useful. 

Having  resorted  to  all  those  means,  we  should,  if  the  symptoms — - 
not  only  of  pain  and  deafness,  but  of  the  redness  and  vascularity  of 
the  tympanal  membrane— remain  unrelieved,  at  once  have  recourse 


232  ACUTE    MYRINGITIS. 

to  the  use  of  mercury.  Indeed  I  am  now  so  fully  convinced,  not 
only  of  the  utility,  but  of  the  urgent  necessity  of  employing  mercury 
in  these  aural  inflammations,  that  I  do  not  hesitate  to  recommend  its 
use  in  the  early  stages  of  all  such  affections.  A  pneumonia,  a  peri- 
carditis, a  peritonitis,  an  inflammation  of  a  large  joint  or  a  serous 
cavity,  or  an  iritis,  may,  it  is  true,  get  well  by  simple  depletion,  &c. ; 
but  will  any  experienced  practitioner  of  the  present  day  risk  such  a 
case  without  having  recourse  to  mercury  ?  For  the  reasons  applica- 
ble in  these  instances, — from  the  peculiar  effect  which  mercury  exer- 
cises, not  only  in  most  inflammations,  but  especially  over  those  of 
fibrous  membranes ;  and  in  order  to  arrest  the  exudation  of  lymph, 
and  to  cause  the  absorption  of  those  effusions  which,  by  thickening 
the  membrane,  and  causing  those  pathological  effects  to  which  I  have 
already  so  frequently  alluded,  and  which  prove  so  constantly  the 
cause  of  subsequent  deafness ;  as  well  as  the  urgent  necessity  for  ar- 
resting the  progress  of  inflammation  in  a  part  that  may  prove  de- 
structive to  life, — it  is,  that  I  so  strongly  advocate  the  employment  of 
this  remedy.  I  find  that,  in  most  instances,  where  it  is  employed 
early,  it  produces,  as  soon  as  it  affects  the  system,  as  well-marked  an 
improvement  in  all  the  symptoms  as  it  does  in  any  of  the  other  in- 
flammations which  I  have  enumerated.  It  should,  therefore,  be  given 
in  small,  frequently-repeated  doses ;  and  the  formula  I  find  most  effi- 
cacious is  calomel  and  blue  pill,  guarded  with  opium,  and,  if  the 
stomach  will  bear  it,  a  very  small  quantity  of  James's  powder.  Not 
only  should  the  gums  be  touched,  but  the^|"patient  should  be  kept 
under  its  gentle  influence  for  some  days,  in  order  to  insure  an  ulti- 
mate beneficial  result. 

In  the  subsequent  management  of  the  disease,  the  iodide  and  bro- 
mide of  potassium,  or  very  minute  doses  of  the  bichloride  of  mercury 
in  some  of  the  preparations  of  bark,  will  certainly  hasten  the  cure, 
as  well  as  promote  absorption  of  the  deposits  and  adhesions  already 
alluded  to.  The  tinnitus  which  remains  is  more  likely  to  be  removed 
in  time  than  that  attending  chronic  deafness. 

The  state  of  the  meatus  and  membrana  tympani  should  be  exa- 
mined with  a  speculum  daily,  or  oftener  if  necessary ;  and  then,  should 
we  discover  the  ulcer,  it  may  be  touched  with  a  solution  of  nitrate  of 
silver  applied  with  a  fine  camel's  hair  pencil.  If  otorrhoea  has  oc- 
curred either  in  the  form  of  muco-serous  exudation,  from  the  external 
surface  of  the  tympanal  membrane  and  the  auditory  canal,  or  owing 
to  pus  or  mucus  escaping  from  the  middle  ear  through  an  aperture 


ACUTE    MTEINGITIS.  233 

in  the  membrana  tympani,  or  from  abscess  in  the  walls  of  the  external 
auditory  canal,  we  should  remove  the  discharge  by  very  gently  syring- 
ing the  part  with  simple  warm  water,  or  the  most  bland,  unirritating 
fluid;  but  dm'ing  the  high  inflammatory  process  no  stringent  injec- 
tions whatever  should  be  employed. 

If  polypoid  growths  of  any  magnitude  sprout  suddenly  from  the 
auditory  canal,  they  should  be  removed  with  the  snare,  or  touched 
with  the  solid  nitrate  of  silver ;  and  this  latter,  if  properly  done,  does 
not  give  rise  to  any  fresh  attack  of  inflammation. 

Should  the  mastoid  process,  or  the  parts  covering  it,  become  en- 
gaged, and  that  the  methods  already  recommended  fail  to  give  relief, 
or  that  even  an  indistinct  sense  of  fluctuation  can  be  discovered,  we 
should  not  long  hesitate  to  make  a  free  incision  in  the  periosteum 
there,  at  least  an  inch  in  length.  In  performing  this  operation,  the 
head  should  be  firmly  secured,  and  supported  against  some  unyield- 
ing substance,  as  the  back  of  a  high  chair,  or  the  breast  of  an  assis- 
tant. A  stout  scalpel  is  the  best  instrument  to  employ :  the  blade 
should  be  grasped  by  the  forefinger  and  thumb,  so  as  to  leave  about 
an  inch  of  it  uncovered  ;  and  inserted  steadily  till  the  point  reaches 
the  bone,  which  it  should  be  made  to  traverse  for  the  full  length  of 
the  incision.  By  this  means  we  secure  complete  division  of  the  peri- 
osteum. With  regard  to  the  line  of  the  incision,  cii'cumstances  may 
require  its  being  made  in  other  directions,  but  I  find  that  it  is  most 
generally  required  parallel  with,  and  about  three-quarters  of  an  inch 
from,  the  attachment  of  the  auricle,  in  order  to  avoid  the  posterior 
aural  artery,  which,  when  divided,  bleeds  profusely.  The  knife 
should  be  drawn  from  below  upwards,  and  from  the  swollen  state  of 
the  parts,  the  depth  which  we  are  sometimes  obliged  to  introduce  the 
instrument  is  often  nearly  an  inch.  The  hemorrhage,  unless  we 
wish  to  extract  blood,  may  be  arrested  by  placing  a  dossil  of  lint 
within  the  incision.  The  cut  surfaces  generally  present  the  brawn- 
like appearance  seen  in  phlegmonoid  erysipelas.  Although  pus  may 
not  have  been  reached  by  the  incision,  still  immediate  relief  is  almost 
invariably  experienced.  The  subsequent  management  of  this  particu- 
lar part  of  such  a  case  must  depend  upon  the  circumstance  of  exfolia- 
tion, &c. 

The  following  cases  exhibit  many  of  the  phenomena  detailed  in  the 
foregoing  description.  They  are  given  at  somewhat  greater  length 
than  would  be  necessary,  were  the  diseases  of  the  ear  as  much  at- 
tended to  by  the  general  physician  or  surgeon  as  they  ought,  or  if 


234  ACUTE    MYRINGITIS. 

the  treatment  of  those  diseases  formed  a  part  of  the  present  system 
of  medical  education  in  these  countries. 

Acute  myringitis  and  tympanitis  in  both  ears,  with  severe  head 
symptoms ;  recovery  under  the  use  of  mercury. 

Master  J — ,  aged  twelve  years,  with  light  hair  and  florid  complex- 
ion (whose  elder  brother  had  been  under  my  care  a  short  time  pre- 
viously for  chronic  inflammation  of  the  left,  and  acute  inflammation 
of  the  right  ear),  had  always  enjoyed  good  health,  and  never  had  any 
aural  aifection,  till  Sunday,  the  1st  of  August,  1847,  when  he  was 
attacked  with  slight  pain  in  the  right  ear.  Upon  the  Friday  pre- 
vious he  had  bathed  in  the  open  sea  five  times,  and  had  dived  fre- 
quently each  time.  Upon  the  day  following  he  bathed  three  times, 
and  also  dived.  He  awoke  on  Sunday  morning  early,  with  some 
pain  in  the  right  ear,  but  made  no  complaint,  as  he  says  it  was  but 
slight;  it  was  accompanied,  hoAvever,  by  a  feeling  of  pressure,  as  if 
something  was  bursting  out  through  the  ear.  He  bathed,  however, 
again,  twice  upon  that  day.  Towards  evening  pain  came  on  in  the 
left  earj  and  increased  greatly  in  the  right.  He  retired  to  rest  early, 
and,  having  been  reminded  of  the  provocation  for  his  pain,  he  made 
no  further  complaint.  About  twelve  o'clock  that  night,  however,  his 
mother  was  awoke  by  his  cries  and  moans,  the  result  of  the  extreme 
agony  which  he  was  then  suffering.  A  neighboring  practitioner  was 
applied  to,  and  some  camphorated  oil  and  laudanum  dropped  into  the 
ear.  This  treatment,  however,  afforded  him  no  relief,  and  he  re- 
mained awake  all  night,  moaning  much,  and  complaining  of  the  vio- 
lent pain  in  his  head  and  ears,  which  he  likened  to  a  sharp  instru- 
ment penetrating  from  without. 

I  saw  him  on  Monday  morning,  the  2d,  about  ten  o'clock;  the 
face  was  flushed,  and  the  countenance  anxious  and  expressive  of  ex- 
treme pain.  The  pupils  were  rather  more  contracted  than  natural, 
and  the  eyes  slightly  sensitive  to  light ;  he  had  some  heat  of  skin,  but 
the  pulse  was  not  above  76  ;  the  bowels  were  constipated,  and  the 
urine  natural.  The  auricle  and  external  meatus  were  normal ;  con- 
siderable pain  was  experienced  upon  pressing  the  cartilage  behind 
the  articulation  of  the  jaw,  but  pressure  over  the  mastoid  region  was 
borne  with  impunity.  The  auditory  canal  was  a  light  rose  color, 
quite  dry,  and  devoid  of  cerumen;  the  membrana  tympani  was  dis- 
tinctly seen,  with  a  deep  pink  color  generally  diffused  over  it,  but 
increasing  in  intensity  in  a  crescentic  form  round  its  lower  insertion, 
and  also  in  the  line  of  the  attachment  of  the  malleus.     The  appear- 


ACUTE    MYRINGITIS.  235 

ances  were  nearly  the  same  on  both  sides.  As  this  boy  was  brought 
to  mj  house,  I  had  a  better  opportunity  of  accurately  recording  the 
state  of  the  parts  than  one  is  usually  able  to  effect  in  the  sick  cham- 
ber. The  appearance  of  the  throat  was  normal ;  the  finger  pressed 
against  the  mouth  of  the  Eustachian  tube  caused  but  slight  increase 
of  the  pain.  Air  passed  up  with  difficulty  into  the  tympanal  cavity 
on  making  a  forced  expiration.     Hearing  was  then  unimpaired. 

He  was  ordered  to  be  put  to  bed ;  to  take  a  pm'gatire  bolus,  and 
to  have  two  leeches  immediately  applied  to  the  posterior  margin  of 
the  external  meatus,  as  far  as  possible,  on  both  sides.  The  leeches 
afforded  some  relief,  but  towards  evening  the  pain  retm'ned  with 
great  violence.  He  became  quite  delirious  about  six  o'clock ;  did  not 
know  his  friends ;  and  could  with  difficulty  be  retained  in  bed.  I 
saw  him  about  eight  o'clock;  he  was  then  in  high  fever,  but  more 
sensible ;  there  was  great  heat  of  skin :  pulse  80,  and  fuller  than  in 
the  morning ;  tongue  clean ;  bowels  had  been  fully  opened ;  urine 
free  and  limpid ;  no  thirst ;  knows  all  his  friends  now,  but  does  not 
pay  much  attention  to  what  is  going  forward  about  him;  is  quite 
rational  when  spoken  to ;  complains  of  intolerance  of  light ;  face  has 
become  more  flushed  and  anxious ;  complains  now  of  the  great  weight 
of  his  head,  which  he  rolls  about  from  side  to  side ;  has  had  no  sleep. 
On  examination  I  found  that  the  redness  of  the  passage  and  membrane 
of  the  drum  had  greatly  increased  since  morning,  but  there  was  no 
tumefaction  of  either.  Pressure  or  percussion  of  the  mastoid  process, 
and  the  infra-aural  region,  was  borne  without  wincing.  Two  more 
leeches  were  ordered  to  be  applied  over  the  articulation  of  the  jaw, 
in  front  of  the  tragus  upon  each  side,  and  small  doses  of  calomel, 
opium,  and  James's  powder  to  be  administered  every  third  hour. 
The  ear  to  be  steamed  over  hot  water,  and  a  linseed  poultice  to  be 
applied  subsequently.     Scarcely  any  diminution  of  hearing. 

3d.  Has  passed  a  sleepless  night,  raving  occasionally.  All  his 
previous  symptoms  continue  unabated,  in  addition  to  which,  he  now, 
for  the  first  time,  complains  of  noise  in  his  ears,  which  he  likens  to 
that  of  the  tide,  and  which  is,  he  says,  generally  diffused  through  the 
head  as  well  as  in  the  ears.  The  pain  has  somewhat  increased ;  he 
says  he  feels  as  if  a  lance  was  running  into  his  head ;  bowels  free. 
Blisters  ordered  to  be  applied  behind  the  ears  upon  both  sides.  During 
the  night  of  Tuesday  he  again  became  violent,  and  did  not  k;iow 
his  friends.    The  urine  became  remarkably  dark-colored.     He  had  no 


236  ACUTE    MYKINGITIS. 

sleep.  The  mercury  was  steadily  persevered  in,  and  towards  morning 
lie  complained  of  some  soreness  of  his  mouth  and  gums. 

4th.  He  passed  another  sleepless  night ;  raved  occasionally ;  coun- 
tenance less  anxious ;  pulse  not  so  full ;  pain  in  ears  and  head  very 
much  less ;  mercurial  fetor ;  mouth  slightly  sore ;  complains  of  pain 
in  swallowing,  which  he  refers  to  the  middle  ear.  He  has  become 
very  deaf;  says  the  noise  has  increased,  and  is  now  of  two  kinds, — a 
continuous,  uninterrupted  bellows  sound,  and  an  occasional  ticking, 
like  '  that  of  a  loud  watch,  which  commences  and  stops  suddenly ; 
membrane  and  passage  unaltered.  Interval  between  doses  of  mercury 
increased. 

5th.  He  is  much  better  in  every  respect ;  has  had  no  delirium  since 
last  report ;  lies  quiet  on  his  side  ;  he  is  remarkably  tranquil,  and  has 
had  some  sleep ;  the  light  is  still  offensive  to  him ;  skin  cooler ;  pulse 
80 ;  bowels  free ;  mouth  very  sore  ;  deafness  still  continues ;  noise  in 
head  not  so  violent ;  urine  high-colored ;  the  membrana  tympani  and 
auditory  canal  are  much  less  red.  Mercury  omitted;  the  occipital 
region = was  ordered  to  be  shaved,  and  two  small  blisters  to  be  applied 
behind  the  insertion  of  the  mastoid  muscles.  His  chief  complaint 
now  is  of  the  soreness  of  his  mouth  from  the  effects  of  the  mer- 
cury. 

6th.  At  eleven  o'clock  this  morning  he  was  suddenly  attacked  with 
acute  pains  in  both  ears,  of  a  sharp  lancinating  character.  Leeches 
were  again  applied  round  the  meatus  on  both  sides,  and  warm  stupes 
and  fomentations  also  had  recourse  to.  These  means  afforded  him 
relief  in  a  short  time. 

7th.  Has  slept  well  dm"ing  the  previous  night ;  had  no  return  of 
the  acute  pain,  but  a  dull  aching  still  continues  in  both  ears ;  he  is 
very  deaf  to-day,  but  he  is  not  so  sensitive  to  light ;  the  bellows  noise 
still  continues  in  his  ears,  and  that  which  was  formerly  described  as 
the  ticking  of  a  watch,  he  now  likens  to  the  clapping  of  two  pieces  of 
iron  together.  He  only  hears  an  ordinary  ticking  watch  when  it  is 
pressed  against  the  auricle  of  the  left  side,  not  at  all  on  the  right ; 
he  does  not  hear  it  when  applied  to  the  forehead,  or  held  between 
the  teeth,  and  but  very  faintly  when  applied  upon  the  mastoid  process. 
He  complains  of  a  return  of  the  weight  in  his  head  to-day ;  sleeps 
much ;  bowels  free ;  urine  of  a  dark  brown  color,  and  depositing  a 
pinkish  sediment ;  mouth  very  sore.  Upon  the  visit  at  four  o'clock  in 
the  evening  the  countenance  was  found  more  tranquil  than  on  any 
previous  occasion ;  the  skin  cool ;  pulse  75 ;  functions  natural :  pres- 


ACUTE    MYRINGITIS.  237 

sure  on  the  tragus  is  now  borne  vath  impunity.  Upon  inspection,  the 
membrana  tympani  was  found  much  less  red,  particularly  on  the  left 
side ;  it  is  also  beginning  to  clear  aboYe  the  malleus ;  mouth  still  very 
sore ;  ordered  a  gargle,  and  to  have  light  broth. 

9th.  Much  better  in  every  respect.  A  slight  muco-pui'ulent  dis- 
charge now  appears  from  the  meatus  of  the  right  ear.  On  removing 
this  with  a  little  tepid  water,  and  bringing  the  membrani  tympani 
within  the  field  of  the  speculum,  the  redness  was  found  to  have  greatly 
disappeared,  except  on  two  or  three  spots,  about  the  size  of  pin-heads  ; 
all  the  intermediate  portions  of  the  membrane  had  become  white,  and 
apparently  thick  and  pulpy.  Upon  the  left  side  a  slight  mucous 
discharge  coats  over  the  sui'face  of  the  membrane  of  the  drum,  and 
the  inferior  portion  of  the  canal ;  having  removed  this  with  a  little 
cotton  on  a  probe,  the  vascularity  which  had  pre^dously  appeared  on 
those  parts  was  found  to  have  greatly  diminished ;  but  the  membrane 
itself  had  become  thickened  and  opaque.  He  is  quite  free  from  pain ; 
the  hearing  distance  has  increased  to  about  two  inches  on  each  side. 
On  the  right  side  two  small  glands  have  now  appeared  beneath  the 
lobe,  and  another  slightly  enlarged  over  the  mastoid  process  ;  ordered 
three  grains  of  the  hydriodate  of  potash  three  times  a  day,  and  nutri- 
tious diet. 

12th.  Has  very  much  improved  in  every  respect  since  last  report ; 
is  now  quite  free  from  fever,  but  very  weak  and  languid;  tongue 
clean ;  soreness  of  mouth  quite  removed ;  pulse  60 ;  has  some  appe- 
tite ;  sat  up  for  a  short  time  yesterday ;  glands  in  the  neck  much 
lessened,  that  over  the  mastoid  process  still  tender;  is  quite  free 
from  pain  in  the  ears,  but  still  complains  of  a  slight,  generally  diffused 
pain  in  his  head ;  there  is  no  intolerance  of  light ;  hearing  distance 
has  increased  to  eighteen  inches  on  each  side ;  has  had  no  discharge 
from  either  ear ;  the  loud  ticking  noise  has  quite  disappeared,  but  the 
buzzing  or  bellows  sound  is  still  slightly  perceptible  ;  any  surrounding 
noise  is  particularly  distressing  to  him ;  he  says  he  feels  as  if  it  struck 
his  ear.  Upon  examination  of  the  right  ear,  the  passage  is  found  to 
be  quite  dry,  and  of  a  light  pink  color ;  the  membrana  tympani  gene- 
rally is  somewhat  redder  than  on  the  occasion  of  my  former  visit ; 
and,  besides  this  generally-diffused  redness,  there  is  a  deep-colored 
ring  of  vessels  to  be  seen,  forming  a  crescentic  band  about  a  line  in 
breadth,  occupying  the  lower  portion  of  the  membrane,  the  vessels  of 
which  can  be  distinctly  seen  running  in  nearly  straight  lines  from 
the  circumference  towards  the  centre.     The  projection  of  the  malleus 


238  ACUTE    MYRINGITIS. 

is  marked  by 'a  fasciculus  of  dark  red  vessels,  running  along  the  course 
of  its  attachment.  In  the  left  ear  the  general  redness  of  the  passage 
and  the  membrane  is  not  so  great,  and  there  is  no  ring  of  vessels  such 
as  exists  upon  the  right  side.  He  states  that,  on  blowing  his  nose,  he 
felt  as  if  something  gave  way  in  his  right  ear,  and  that  immediately 
his  hearing  increased,  and  on  repeating  the  experiment  a  few  times, 
the  same  phenomena  took  place  in  the  left  ear.  Since  then  his  hear- 
ing has  gradually  improved  to  the  present  time ;  he  was  ordered  to  be 
blistered  again  behind  the  ears,  to  continue  the  use  of  the  potash,  to 
sit  up  for  a  few  hours  every  day,  and  have  nutritious  diet. 

16th.  Has  continued  to  improve ;  hearing  has  increased  to  three 
feet  upon  the  right,  and  four  feet  upon  the  left  side.  The  right 
membrana  tympani  is  found  much  less  vascular  but  somewhat  more 
opaque  than  the  left,  which  is  still  of  a  uniform  pinkish  color,  but 
has,  nevertheless,  regained  its  polish  and  semitransparency  much 
more  than  the  other.  The  buzzing  noise  is  still  slightly  felt.  The 
blisters  were  repeated,  and  the  potash,  with  tincture  of  iodine,  con- 
tinued-; slight  open  air  exercise  permitted. 

18th.  From  the  general  improvement  in  his  health,  he  was  enabled 
to  visit  me  at  my  house  on  this  date.  He  states  that  the  buzzing  and 
all  other  noises  have  completely  disappeared.  The  membrana  tym- 
pani on  the  right  side  is  found  to  have  lost  much  of  its  vascularity, 
but  is  uniformly  opaque,  and  is  also  dull  upon  its  surface ;  with  this 
ear  the  hearing  distance  is  now  four  feet,  whereas  with  the  left,  vfhich 
is  still  very  vascular,  but  much  more  transparent,  the  hearing  distance 
is  now  full  six  feet.  A  generous  diet,  and  the  potash  and  iodine 
ordered  to  be  continued. 

Sept.  25th.  His  general  health  is  now  quite  restored ;  his  hearing 
as  good  as  ever ;  the  noise  has  entirely  disappeared.  During  the 
past  month  a  blush  of  redness  has  several  times  appeared  upon  the 
the  left  membrana  tympani ;  still  his  hearing  distance  with  that  ear 
is  somewhat  greater  than  on  the  right  side,  in  which  the  membrane 
is  not  vascular,  but  is  slightly  opaque. 

The  constitutional  symptoms  in  this  case  were  more  than  usually 
severe,  and  such  as  might  lead  the  practitioner  to  suppose  the  brain 
or  its  membranes  were  engaged.  We  also  learn  from  this  case  that 
inflammation  of  the  tympanum  and  its  membrane  may  produce  such 
a  degree  of  deafness  as  that  the  watch  cannot  be  heard,  even  when 
applied  to  the  ear. 

In  all  probability  the  inflammation  commenced  and  was  originally 


ACUTE    MYRINGITIS.  239 

confined  to  the  tympanal  membrane,  and  afterwards  extended  to  the 
middle,  and,  possibly,  the  internal  ear. 

From  the  latter  stage  of  this  boy's  case  we  also  learn  a  fact  worthy 
of  observation,  namely,  that  it  is  not  the  amount  of  vascularity,  but 
the  degree  of  thickening  and  opacity  in  the  membrana  tympani, 
which  produces  the  deafness. 

The  next  is  a  case  of  acute  myringitis  and  tympanitis  of  one  side ; 
and  immediate  recovery  under  the  use  of  mercury. 

C.  L.,  a  female,  aged  21,  applied  at  the  hospital  at  ten  o'clock  on 
the  morning  of  the  18th  of  April,  1846,  for  an  attack  of  intense 
pain  in  her  right  ear.  She  states  that  she  has  not  been  "regular" 
for  the  last  six  weeks ;  that  she  was  attacked  four  days  ago  with  ca- 
tarrh, attended  with  considerable  stuffing  in  her  nose,  and  the  other 
usual  symptoms  of  that  affection  ;  that  she  had  walked  along  the  sea- 
shore the  day  before,  with  a  cold  wind  blowing  upon  her  right  side. 
She  went  to  bed  tolerably  well  last  night,  but  awoke  at  three  o'clock 
this  morning  with  a  violent  beating  pain  in  her  ear,  accompanied  by 
a  loud  noise,  which  she  likens  to  the  "puffing  of  a  steam-engine;" 
the  pain  resembles  that  of  a  sharp  instrument  penetrating  through 
her  ear  into  her  head,  which  she  describes  as  most  excruciating.  She 
had  also  some  pain  and  soreness  over  that  side  of  the  head ;  she  felt 
some  difficulty  of  deglutition,  owing  to  the  pain  it  caused  her. 
Coughing,  sneezing,  or  any  motion  of  the  temporo-maxillary  articu- 
lation, greatly  aggravated  her  sufferings,  and  gave  her  a  feeling  of 
bursting  in  the  middle  ear. 

She  rose  at  seven  o'clock,  felt  great  sickness  of  stomach,  and  had 
a  well-marked  rigor  whilst  dressing.  She  immediately  applied  to  a 
neighboring  practitioner,  who  put  some  "  drops"  with  a  piece  of  cot- 
ton into  her  ear,  which  only  aggravated  her  symptoms.  Her  pain 
still  continues,  and  the  noise  has  increased ;  there  is  slight  redness 
and  great  heat  of  the  auricle.  The  pain  is  increased  on  making 
pressure  over  the  tragus  in  front  of  the  meatus ;  on  pressing  or  per- 
cussing the  mastoid  process  slight  pain  is  also  complained  of.  The 
pain  in  her  ear,  however,  is  not  increased  by  these  means,  nor  is  it 
referred  to  the  tympanum.  She  has  no  pain  beneath  the  meatus,  nor 
behind  the  angle  of  the  jaw.  The  hearing  distance,  with  an  ordinary 
ticking  watch,  is  scarcely  three  inches  in  the  right  ear.  On  closing 
the  meatus  of  the  left  side,  the  noise  is  greatly  increased.  On  exami- 
nation with  a  speculum,  the  auditory  canal  is  found  highly  vascular, 
dry,  devoid  of  cerumen,  and  exceedingly  tender  to  the  touch.     The 


240  ACUTE    MYRINGITIS. 

membrana  tympani  has  lost  its  polish,  and  is  of  a  bright,  florid,  gene- 
rally-diffused red  color,  spotted  with  small  patches  of  a  deeper  hue, 
like  minute  ecchymoses.  The  projection  of  the  malleus  can  be  recog- 
nised, of  a  darker  color  than  the  surrounding  parts,  with  a  whitish 
line  in  the  centre.  Below  the  malleus,  and  towards  the  posterior 
part  of  the  membrane,  a  well-defined  vesicle,  about  the  size  of  a  grain 
of  mustard  seed,  and  filled  with  a  brownish  fluid,  can  be  seen.  Upon 
holding  the  mouth  and  nose,  and  pressing  the  air  into  the  Eustachian 
tube,  she  experiences  considerable  difiiculty  in  making  it  pass  up  upon 
that  side,  while  it  passes  with  facility  into  the  tympanum  of  the  left. 
The  ear,  or  a  stethoscope,  held  to  the  right  side  during  this  operation, 
readily  perceives,  as  soon  as  the  air  reaches  the  tympanum,  a  squeel- 
ing  and  gurgling  sound,  as  if  the  air  passed  not  only  through  a  nar- 
row passage,  but  through  a  fluid-like  mucus.  This  pressure  of  air 
into  the  tympanum  greatly  agrravates  her  symptoms. 

Upon  looking  into  the  mouth,  the  fauces,  uvula,  and  back  of  the 
pharynx  are  found  nearly  of  their  natural  color.  Upon  inserting 
the  forefinger  of  the  right  hand  into  the  mouth,  and  pressing  its 
point  upwards,  backwards,  and  outwards,  towards  the  mouth  of  the 
Eustachian  tube,  considerable  increase  of  pain  is  experienced  in  the 
middle  ear.  The  tongue  is  coated  ;  the  pulse  regular ;  but  there  is 
heat  of  skin,  and  considerable  anxiety  of  countenance.  The  left  ear 
is  natural  in  function  and  appearance.  This  patient  sufiered  from 
rheumatism  of  the  upper  extremities  some  time  ago. 

Four  leeches  were  applied  around  the  meatus,  as  far  in  as  possible, 
and  four  in  the  depression  in  front  of  the  tragus.  She  was  or- 
dered to  foment  and  steam  the  ear  over  hot  water,  placed  in  the  bot- 
tom of  a  long  narrow  mug,  frequently  during  the  day ;  and  a  purge 
was  administered. 

19th.  States  that  she  received  immediate  relief  from  the  leeching. 
The  countenance  is  less  anxious,  and  she  slept  well  all  night ;  the 
noise  of  a  steam-engine  is  altered  to  a  gurgling  sound ;  the  pain  and 
all  other  symptoms  are  relieved ;  the  membrana  tympani,  however, 
remains  nearly  the  same  in  color,  but  the  vesicle  has  become  flaccid. 
She  was  put  on  the  use  of  calomel  and  opium  in  small  doses  frequent- 
ly repeated ;  a  blister  was  applied  over  the  mastoid  process ;  the 
fomentation  and  warm  vapor  was  ordered  to  be  continued,  and  a  lin- 
seed-meal poultice  to  be  applied  to  the  external  ear  at  bedtime. 

20th.  Continues  to  improve.  Noise  changed  to  that  of  the  ring- 
ing of  bells ;  the  pain,  on   pressing   the   mouth  of  the  Eustachian 


ACUTE    MYRINGITIS.  241 

tube,  is  much  less ;  tlie  membi-ana  tympani  is  less  vascular ;  tlie  gene- 
ral symptoms  have  all  improved ;  the  mercury  to  be  continued. 

21st.  All  the  symptoms  relieved ;  the  mouth  is  slightly  sore ;  no 
pain  on  pressing  anywhere  around  the  ear  or  meatus ;  all  heat  and 
vascularity  of  auricle  is  removed ;  the  membrana  tympani  has  lost 
its  vascularity,  but  is  slightly  more  opaque,  and  whiter  than  natui-al ; 
the  vesicle  has  quite  disappeared ;  three  or  four  large  vessels  can  still 
be  seen  coui'sing  along  the  handle  of  the  malleus.  Upon  forcing  air 
through  the  Eustachian  tube  into  the  tympanum,  a  slight  gurgling 
noise  can  be  perceived  in  the  middle  ear,  and  of  the  peculiar  sensa- 
tion which  it  imparts  the  patient  is  quite  conscious.  During  this  ope- 
ration, and  while  the  membrana  is  within  the  field  of  the  speculum, 
a  slight  blush  of  redness,  of  a  pinkish  hue,  is  observed  to  be  pro- 
duced ia  the  membrane.  The  hearing  distance  has  increased  to  four 
inches.  A  copious  red  deposit  was  observed  in  the  m-ine.  She  has 
been  slightly  purged  by  the  mercury ;  ordered  to  lessen  its  dose  to 
one  pill  night  and  morning. 

23d.  Continues  to  improve  in  hearing ;  noise  as  before ;  she  has 
had  no  return  of  pain  in  the  ear ;  the  pain  and  soreness  in  the  head 
gone ;  no  flying  pains  or  other  rheumatic  afiFection ;  the  mouth  is  very 
sore :  ordered  to  omit  the  pills,  and  take  the  sixteenth  of  a  grain  of 
oxymuriate  of  mercury  with  decoction  and  tincture  of  bark  three 
times  a  day ;  generous  diet. 

25th.  Continues  to  improve  rapidly ;  membrana  tympani  is  more 
transparent  than  upon  last  examination.  Hearing  distance  is  in- 
creased to  twelve  inches  ;  slight  pain  is  still  felt  on  pressure  over  the 
lower  portion  of  the  mastoid  process,  and  opposite  the  point  of  the 
styloid  process,  in  which  latter  place  it  is  still  increased  on  coughing. 
Ordered  to  continue  the  oxymuiiate  and  bark,  and  to  apply  another 
blister. 

All  her  symptoms  have  now  disappeared,  with  the  exception  of  a 
slight  buzzing  occasionally ;  the  hearing  is  perfectly  restored. 

Four  months  later  I  had  an  opportunity  of  examining  this  young 
woman  again ;  her  hearing  had  been  quite  restored ;  but  she  said  that 
she  occasionally  suffered  from  a  slight  "  ticking  noise."  The  mem- 
brane of  the  drum  upon  the  effected  side  presented  a  slight  mottled 
appearance,  particularly  towards  its  lower  edge,  but  without  an  opacity 
of  any  account ;  her  hearing  distance  is  two  feet  less  upon  the  right 
side  than  the  left. 

March,  1851.  She  had  a  slight  attack  of  pain  in  the  right  ear,  ac- 

16 


242  ACUTE    MYRINGITIS    AYITH    OTITIS. 

companied  by  some  deafness  and  redness  of  the  membrana  tympanic 
all  of  whicli  were  at  once  removed  by  the  application  of  leeches. 

January,  1852.  She  has  not  had  any  return  of  pain  or  deafness ; 
parts  natural ;  hearing  normal ;  no  tinnitus. 

INFLAMMATION   OP  THE   MEMBRANA   TYMPANI  AND    OTITIS. 

Case  of  severe  rheumatic  inflammation  of  the  membrana  tympani 
and  cavity  of  the  tympanum,  with  periostitis,  polypus,  &c. 

Mr.  F.,  aged  49,  with  light  hair  and  fair  complexion,  suffered 
several  years  ago  from  a  severe  attack  of  rheumatism,  in  which  his 
heart  was  affected,  caught  while  exposed  to  a  cold  wind  upon  the  top 
of  a  coach  during  a  long  journey ;  since  that  period  he  has  been  very 
liable  to  catch  cold,  in  the  head  particularly,  whenever  the  feet  are 
exposed  to  damp  or  low  temperature.  These  attacks  of  catarrh  were 
characterized  by  violent  fits  of  sneezing  and  running  at  the  nose,  &c. ; 
latterly  his  sense  of  smelling  became  greatly  impaired,  and  he  per- 
ceived %  stuffing  in  the  right  nostril  which  rendered  him  very  uncom- 
fortable. During  the  summer  of  1846  he  was  attacked,  in  addition 
to  the  catarrhal  affection,  with  cough,  expectoration,  and  other  symp- 
toms of  bronchitis.  Having  recovered  from  this,  he  remained  in  good 
health  till  January,  1847,  on  the  28th  of  which  month,  during  a  period 
of  very  wet  and  severe  weather,  his  present  attack  commenced.  His 
own  words  are  :  "  About  this  period  I  wore  a  muffler  about  my  neck ; 
one  sharp  morning  I  walked  into  my  office,  laid  it  aside  on  my  arrival, 
and,  being  called  off  suddenly  to  the  Four  Courts,  I  forgot  to  put  it 
on  again.  On  my  way  there  I  felt  a  blast  of  sharp,  cold  air  strike 
my  throat  on  the  right  side,  under  the  ear,  but  I  did  not  pay  much 
attention  to  it,  and  remained  in  Court  most  of  the  day,  with  my  hat 
off  occasionally.  About  two  o'clock  I  felt  a  slight  pain  in  the  right 
ear,  and  got  a  bit  of  cotton  wool  put  into  it ;  about  six  o'clock  I  re- 
turned home  from  my  office.  I  called  at  my  apothecary's  Avho  dropped 
some  warm  oil  and  laudanum  into  my  ear,  which,  for  a  time,  lessened 
the  pain,  but  did  not  completely  remove  it ;  but  I  was  enabled  to  resume 
my  business  as  usual  next  day." 

Mr.  Collins,  to  whom  Mr.  F.  first  applied,  writes  to  me  as  follows : 
"  When  Mr.  F.  first  called  upon  me  he  complained  of  pain  in  his  right 
ear,  and  also  of  slight  shooting  pains  about  that  side  of  the  head ;  he 
looked  a  little  dull  and  heavy,  but  there  was  no  fever,  quickness  of 
pulse,  headache,  deafness,  or  other  symptoms  of  importance  present. 


ACUTE    MYEINaiTIS    "WITH    OTITIS.  243 

I  considered  Ms  attack  to  be  of  a  rheumatic  or  neuralgic  character, 
particularly  as  lie  liad  suffered  a  few  years  before  from  severe  rheu- 
matic fever ;  and  as  the  pain  in  the  ear  was  what  he  most  complained 
of,  I  dropped  some  tincture  of  opium  and  olive  oil  into  it,  and  applied 
a  bit  of  wool  to  prevent  its  coming  out ;  I  also  ordered  him  an  ape- 
rient. Upon  the  next  evening  Mr.  F.  again  applied  to  me  on  his  re- 
turn from  Court,  and  stated  that  he  had  derived  relief  from  the  drops 
until  he  was  again  exposed  to  cold  and  draughts  that  day :  the  drops 
were  again  applied  and  with  relief.  The  next  day  Mr.  F.  resumed 
his  usual  avocations,  but  the  pain  continued  to  increase,  and  four 
leeches  were  applied  behind  the  ear,  and  a  poppy  fomentation  and  a 
poultice  applied  with  considerable  relief,  though  some  slight  pain  still 
remained  in  the  ear  and  the  side  of  the  head.  His  sense  of  smelling  now 
returned,  and  continued  perfect  for  a  few  days,  when  it  was  again  lost. 
Mr.  F.  confined  himself  to  the  house  for  the  next  two  or  three  days 
but  would  not  consent  to  do  so  longer,  as  he  felt  much  relieved  of 
the  j)ain,  and  business  of  great  importance  required  his  attention  at 
his  ofiice.  In  a  few  days  from  this  date  his  former  symptoms  retm^ned, 
to  relieve  which  he  was  strongly  recommended  by  a  non-medical  friend 
to  drop  into  the  ear  a  liniment  of  oil  of  turpentine  and  oil  of  cinnamon, 
which  I  prepared  for  him,  but,  having  experienced  no  benefit  from 
this,  he  applied  to  you." 

I  first  saw  this  gentleman  upon  the  13th  February ;  he  complained  of 
acute  pain  in  his  right  ear,  which,  as  appears  from  the  foregoing  ac- 
count, had  continued  off  and  on  during  the  previous  fortnight.  The 
pain  here  described  as  "  shooting  from  the  ear  to  the  temple  and  top 
of  the  head,  accompanied  with  a  boiling  and  pumping  noise,  like  that 
of  a  steam-engine ;"  the  pain  also  appeared,  according  to  his  own  de- 
scription, to  reach  to  the  throat,  without  making  the  throat  sore  ;  it 
was  increased  by  sneezing,  but  relieved  by  pressing  the  hand  upon  the 
ear  and  side  of  the  head.  The  auricle  was  hot  and  somewhat  swollen  ; 
the  lining  of  the  meatus  and  auditory  canal  was  red,  tumid,  and  com- 
pletely devoid  of  cerumen ;  the  introduction  of  the  speculum,  and  the 
examination,  caused  a  good  deal  of  pain  from  the  tenderness  of  the 
parts ;  the  membrana  tympani  was  of  a  dark,  brown-red  color,  had 
lost  its  polish,  and  appeared  to  be  swollen  and  pressed  outwards  :  the 
projection  of  the  malleus  could  not  be  discerned ;  pressm-e  in  front  of 
the  ear  gave  a  good  deal  of  pain,  but  there  was  no  tenderness  over  the 
mastoid  process.  Rest,  abstinence,  confinement  to  the  house,  constant 
fomentations,  leeches  round  the  meatus,  with  small  doses  of  blue  pill, 


244  ACUTE    MYRINGITIS    WITH    OTITIS. 

James's  powder,  and  hyoscyamus,  at  night :  and  an  aperient  in  the 
morning,  was  the  treatment  resorted  to  during  the  next  few  days. 

Upon  the  19th,  his  symptoms,  with  the  exception  of  the  pain  in  the 
ear,  continued  much  the  same ;  he  had  also  flying  pains  of  a  rheumatic 
character  in  the  side  of  the  head,  the  wrists,  feet,  and  generally 
throughout  the  body.  The  pumping  and  boiling  noise  remained  una- 
bated :  the  deafness  now  became  complete  upon  that  side.  The  ap- 
pearance of  the  ear  continuing  unchanged,  except  that  the  meatus  was 
more  swollen,  it  was  deemed  advisable  to  place  him  under  the  influence 
of  mercury, — an  opinion  in  which  Dr.  Stokes,  who  saw  him  with  me, 
at  that  time  concurred.  He  was  accordingly,  but  with  some  difficulty, 
mercurialized  by  means  of  small  and  frequently  repeated  doses  of 
blue  pill,  calomel,  and  opium.  When  his  mouth  became  sore,  the  pain 
in  the  ear  and  the  noise  lessened  somewhat,  and  the  general  rheumatic 
affection  disappeared ;  but  the  meatus  and  auditory  canal  now  became 
so  much  decreased  in  calibre,  owing  to  the  thickening  of  the  lining  of 
these  parts,  that  it  was  not  possible  to  gain  more  than  a  glimpse  of  the 
red  and  "swollen  membrana  tympani.  The  leeching  and  blistering  were 
continued,  and  the  surfaces  denuded  by  the  latter  were  dressed  vfith  ex- 
tract of  belladonna  and  mercurial  ointment. 

March  10th.  The  cuticle  became  detached,  and  a  slight  muco-puru- 
lent  discharge  took  place  from  the  external  meatus ;  the  ear  was  then 
syringed  with  plain  tepid  water  ;  he  was  allowed  a  more  generous  diet, 
and  placed  upon  the  use  of  the  hydriodate  of  potash,  with  infusion  of 
bark  and  tincture  of  orange  peel.  His  general  health  now  improved ; 
he  slept  better,  and  was  able  to  go  abroad  and  take  exercise ;  the  dis- 
charge, however,  continued  to  increase,  and  emitted  a  very  offensive 
odor ;  and,  at  the  same  time,  he  began  to  complain  of  a  deep-seated 
soreness  all  over  the  side  of  the  head,  behind  the  ear,  but  particularly 
over  the  mastoid  process  and  immediately  below  it.  ToAvards  the  end 
of  March,  upon  examining  the  ear  carefully  under  a  good  light,  a 
small  polypoid  excrescence  of  a  light  red  color,  growing  from  the  pos- 
terior wall  of  the  canal,  and  completely  filling  up  the  cavity,  was  de- 
tected ;  this  I  removed  with  a  wire  snare  and  the  discharge  then  les- 
sened ;  the  soreness  of  the  side  of  the  head,  the  pumping,  and  the 
deafness,  however,  remained  the  same.  Pressure  over  the  mastoid 
process  and  the  post-aural  region  of  the  head,  very  much  increased 
the  soreness,  and  it  was  now  evident  that  the  periosteum  covering 
these  parts  was  inflamed. 

During  the  latter  part  of  the  month  of  April,  and  all  the  month  of 


ACUTE    MYRINGITIS    WITH    OTITIS.  245 

May,  tlie  symptoms  of  periostitis  remained  much  the  same,  and  the 
scalp  itself  became  inflamed,  ha\dng  a  dusky,  red  hue,  pitting  on  pres- 
sure, and  feeling  excessively  sore  to  the  touch.  The  treatment  con- 
sisted in  the  frequent  abstraction  of  blood  from  the  affected  part  by 
means  of  a  few  leeches,  and  a  small  cupping-glass  applied  over  the 
leech-bites ;  poulticing,  inunction  with  different  ointments,  both  of  a 
sedative  and  absorbent  natm'e,  slight  vesicants,  &c.,  and  change  of 
air.  Bark,  potash,  and  iodine  were  also  taken  with  a  view  to  improve 
the  general  state  of  the  constitution.  He  had  no  headache,  rigors, 
or  perspirations,  and  his  sleep  and  appetite  were  tolerably  good ;  still, 
however,  the  pain  continued,  and  the  dusky  redness  and  tumefaction 
of  the  scalp  remained,  although  there  was  no  evidence  of  suppuration. 
It  was  determined,  in  consultation  with  Mr.  Cusack,  to  make  an  inci- 
sion down  to  the  bone,  and  thus  free  the  periosteum,  and  give  exit  to 
any  matter  which  might  be  contained  beneath  it.  Accordingly  upon 
the  29th  of  May,  I  made  a  perpendicular  incision,  about  two  inches 
long,  nearly  parallel  with  the  posterior  margin  of  the  auricle,  by  in- 
serting a  sharp-pointed  scalpel  down  to  the  bone  at  the  point  of  inser- 
tion of  the  mastoid  muscle,  and  carrying  it  upwards  and  a  little  back- 
wards. The  bone  did  not  feel  rough  or  gritty  under  the  knife.  A 
pledget  of  lint  was  inserted  into  it ;  and  when  the  hemorrhage  had 
ceased,  a  linseed-meal  poultice  was  applied  over  it.  The  wound  sup- 
purated kindly,  and  all  the  surrounding  soreness  of  the  scalp  and  pain 
on  pressure  soon  disappeared.  As  the  discharge  from  the  wound  in- 
creased, that  from  the  meatus  lessened,  and  in  about  ten  days  the 
wound  itself  healed  without  any  exfoliation  of  bone.  The  pumping 
noise  now  ceased  altogether,  the  discharge  from  the  ear  also  lessened 
very  much,  and  all  uneasiness  in  the  parts  ceased. 

During  the  month  of  July,  and  till  the  12th  of  August,  I  only  saw 
Mr.  F.  occasionally.  Upon  examining  the  ear  carefully  at  this  latter 
date,  I  perceived  that  the  meatus  had  regained  its  natural  size,  and  I 
discovered  another  second  small  polypus  in  the  situation  of  the  first ; 
this  I  also  removed,  and  Mr.  F.  came  to  me  in  a  day  or  two  to  in- 
form me  that  the  discharge  had  now  ceased  altogether,  and  that  the 
hearing  had  returned  the  night  after  I  had  extracted  the  polypus. 
He  could  now  perceive  the  ticking  of  a  watch  at  the  distance  of  an 
inch  from  his  ear,  although  he  was  quite  unconscious  of  it  when 
pressed  against  the  auricle  the  day  I  last  saw  him.  I  could  now  dis- 
tinguish the  membrana  tympani  perfectly;  it  was  of  a  dull  white 
color,  evidently  much  thickened,  but  not  perforated  in  any  part. 


246  ACUTE    MYEINGITIS    WITH    OTITIS. 

September  3d.  He  has  continued  to  improve  in  every  respect ; 
his  health  and  spirits  are  quite  restored ;  all  discharge  from  the  ear  has 
ceased ;  the  tinnitus  aurium  now  consists  of  a  slight  "  booing  "  which 
appears  occasionally :  the  hearing  is  slowly  returning.  The  snuffling 
and  loss  of  smell  I  now  found  to  be  caused  in  a  great  measure  by  a 
small  gelatinous  polypus  which  filled  up  the  cavity  of  the  right  ante- 
rior naris,  upon  removing  which,  both  the  nasal  respiration  and  the 
sense  of  smell  were  much  improved. 

This  case  is  instructive,  as  showing  the  rheumatic  character  of 
some  of  the  inflammations  of  the  ear,  and  as  exhibiting  the  occasional 
failure  of  the  mercurial  treatment  to  cut  short  the  disease,  particu- 
larly if  it  has  advanced  to  any  height,  as  this  had.  The  discharge 
came  from  the  external  ear  and  the  polypus.  This  morbid  polypoid 
growth,  thus  appearing  during  the  progress  of  an  inflammation, 
should  always  lead  the  practitioner  to  suspect  mischief  going  on  in 
the  neighborhood,  and  should  cause  him  to  examine  with  great  care 
the  condition  of  the  mastoid  process  and  its  coverings,  although 
neither  'the  existence  of  a  polypus,  nor  the  foetor  or  dark  color  of  the 
discharge,  are  of  themselves  a  sufficient  proof  of  caries  or  denuded 
bone.  The  appearance  of  periostitis,  even  at  this  late  period,  is  not 
an  unusual  consequence  of  violent  otitis  ;  the  inflammation  may  spread 
from  the  periosteum  lining  the  bony  portion  of  the  meatus  ;  or  the 
mastoid  cells  may,  and  often  are,  the  seat  of  inflammation,  and  this 
inflammation  may  extend  from  the  layer  of  bone  which  covers  them 
to  the  periosteum.  If  not  relieved  by  such  local  and  general  means 
as  were  made  use  of  in  the  early  part  of  the  foregoing  case,  the  sur- 
geon should  not  hesitate  to  cut  down  upon  the  covering  of  the  bone, 
and  divide  it  fairly  for  an  inch  or  more  of  its  length.  Almost  imme- 
diate ease  follows  this  operation,  even  though  we  fail  to  discover  the 
existence  of  pus  ;  and,  moreover,  delay  after  a  certain  period  may 
prove  fatal.  A  thin  shell  of  bone  is  occasionally  thrown  ofi"  in  such 
cases,  but  not  always.  Generally  speaking,  the  otorrhoea  lessens 
when  the  discharge  from  the  wound  is  fully  established,  although 
there  may  not  be  any  communication  whatever  between  the  parts 
from  which  these  discharges  come.  When  this  pain  over  the  mas- 
toid process  appears  early  in  the  disease,  and  is  accompanied  by  an 
erysipelatous  redness  and  cBdema  of  the  scalp,  we  should  not  hesitate 
in  having  recourse  to  incision  immediately. 

We  have  in  this  case  another  remarkable  example  of  a  mechanical 
impediment,  such  as  the  polypus,  so  completely  obstructing  sound. 


SUBACUTE    MYRINGITIS.  247 

tliat  a  watch  held  to  the  ear  was  not  perceived,  althougli  "hearing  re- 
turned within  a  few  hours  when  that  mechanical  obstruction  was  re- 
moved. There  can  be  little  doubt  of  the  middle  ear  having  been 
engaged  in  this  inflammation,  yet  we  have  no  evidence  of  perforation 
of  the  membrane  of  the  drum  having  taken  place.  The  only  treat- 
ment subsequently  employed  with  Mr.  F.  was  that  of  occasionally 
washing  over  the  auditory  canal  and  membrana  tympani  with  a  solu- 
tion of  nitrate  of  silver. 

SUBACUTE  MYRINGITIS. 

Besides  the  acute  form  of  the  disease,  attended  by  violent  pain, 
&c.,  already  described,  there  is  a  description  of  subacute  injiamma- 
tioji^  of  the  membrana  tympani,  with  which  I  have  been  long  familiar, 
and  which,  although  perfectly  painless,  is  equally  destructive  to  hear- 
ing. It  generally  appears  in  j)ersons  between  15  and  30.  The  first 
symptom  to  which  the  patient's  attention  is  directed  is  deafness, 
which  has  appeared  rather  suddenly.  It  may  be,  but  is  not  necessa- 
rily, accompanied  by  tinnitus ;  but  there  is  always  a  feeling  of  stuff- 
ing in  the  ear ;  the  same  stuffing  is  felt  in  the  nose  and  frontal  sinus ; 
the  patient  complains  of  there  being  a  veil  between  him  and  the 
sound.  The  tympanal  cavity  is  usually  free ;  and  when  it  is  not, 
blowing  the  nose  or  sneezing  sometimes  suddenly  restores  the  hear- 
ing :  and  this  is  one  of  the  causes  why  the  disease  is  so  frequently 
neglected,  the  patient  expecting  a  similar  effect  from  day  to  day. 
The  nature  of  the  disease  is  only  to  be  learned  by  a  careful  inspec- 
tion of  the  membrane,  which,  if  we  see  the  disease  early,  is  always 
of  a  pink  color,  of  a  tint  somewhat  paler  than  that  of  the  monthly 
rose.  Through  this,  dispersed  in  various  directions,  we  may  observe 
in  some  cases  a  few  long,  tortuous  vessels.  The  transparency  and 
polish  of  the  membrane  are  seldom  much  affected  at  first.  The  audi- 
tory canal  does  not  usually  exhibit  signs  of  disease,  but  the  cerume- 
nous  secretion  is  arrested.  Generally  speaking,  there  are  no  consti- 
tutional symptoms  present,  and  when  tinnitus  is  an  accompaniment, 
it  is  usually  of  a  very  light  character,  resembling  a  slight  buzzing  or 

'  Dr.  Kramer  has,  in  the  latest  edition  of  his  Ohrenkrankheiten,  found  much  fault  with  * 
my  classification  of  the  inflammations  of  the  membrana  tympani.  Upon  a  careful  re- 
vision of  my  opinions,  and  five  years'  additional  experience  of  these  diseases,  I  see  no 
reason  to  discard  any  of  the  forms  of  disease  which  I  originally  published,  although 
the  present  arrangement  is  somewhat  different.  Had  Dr.  Kramer  accustomed  his  eye 
to  distinguish  the  different  ophthalmic  inflammations,  he  might  have  been  able  to  ap- 
preciate the  various  shades  of  color  on  the  membrana  tympani. 


248  SUBACUTE    MYRINGITIS. 

singing.  If  allowed  to  proceed  unchecked,  tlie  membrane  becomes 
thickened  and  remarkably  opaque,  from  lymphy  deposits,  and  the 
deafness  which  ensues  is  of  a  most  irremedial  nature.  Collapse  or 
drawing  inwards  of  the  membrana  tympani  does  not  usually  follow 
this  form  of  the  affection,  but  ulceration,  even  to  perforation  of  the 
membrane  of  the  drum,  is  not  an  uncommon  attendant  upon  it. 

This  disease  is  slow  in  its  progress,  and  requires  very  careful 
watching.  Cases  of  this  nature  have  been,  I  feel  convinced,  repeat- 
edly treated  as  "  nervous  deafness."  I  am  inclined  to  think  that  it 
is  a  true  myringitis,  in. which  the  inflammation  is  seated  in  the  fibrous 
layer  of  the  membrane.  In  this  disease  mercury  is  just  as  necessary 
as  in  that  already  detailed  ;  it  should,  however,  be  given  after  a  diffe- 
rent fashion :  to  be  effectual,  it  must  be  slowly  introduced  into  the 
system,  so  as  to  produce  a  steady  and  gradual  effect.  The  mouth 
should  be  kept  sore  until  there  is  a  decided  improvement  both  in  the 
vascularity  and  in  the  hearing,  or  until  all  hope  of  restoration  has 
been  abandoned,  or  other  circumstances  induce  us  to  relinquish  this 
mode  of  treatment.  After  the  constitution  has  been  fully  affected 
by  the  mineral,  the  bichloride,  given  in  doses  from  the  sixteenth  to 
the  eighth  of  a  grain,  dissolved  in  proof  spirits,  and  taken  in  half  an 
ounce  of  the  cold  infusion  of  bark,  and  a  scruple  or  half  a  drachm  of 
Huxham's  tincture,  three  times  a  day,  will  be  found  highly  efficacious. 
The  preparations  of  iodine  are  also,  in  the  advanced  stages  of  the 
disease,  worthy  of  trial ;  but  I  do  not  think  that  the  preparations  and 
combinations  of  iron  produce  in  aural  inflammations  the  same  benefit 
which  they  do  in  constitutions  laboring  under  ophthalmic  affections 
of  a  like  character. 

Counter-irritation  over  the  mastoid  process,  change  of  air,  removal 
to  the  sea,  and  generous  living,  will  hasten  the  cure. 

To  relieve  tinnitus  aurium,  after  the  inflammatory  action  has  been 
subdued,  or  the  original  disease  which  produced  it  has  subsided,  and 
particularly  in  cases  where  we  find  this  symptom  present  without  any  ■ 
apparent  lesion  of  the  parts  we  are  able  to  inspect,  I  have  found  the 
preparations  of  the  Arnica  montana  of  decided  benefit ;  indeed  it  is 
,  the  only  medicine  with  which  I  am  acquainted  that  seems  to  possess 
a  specific  power  over  this  annoying  and  usually  most  intractable  com- 
plaint. The  preparation  I  find  most  efficacious  is  the  tincture  both 
of  the  flowers  and  leaves,  of  which  the  patient  should  commence  by 
taking  fifteen  drops  in  a  tablespoonful  of  the  infusion  of  Arnica,  with 
some  cordial  tincture  three  times  a  day.     After  a  few  days  the  dose 


SUBACUTE    MYRINGITIS.  249 

should  be  increased  one  or  two  drops  daily,  till  it  reaches  thirty,  or 
even  more,  unless  headache  or  giddiness  be  produced,  when  we  should 
at  once  lessen  the  dose,  or  omit  the  medicine  altogether  for  a  short 
time.^  The  state  of  the  bowels  should  be  carefully  attended  to 
during  the  administration  of  this  drug. 

So  long  as  any  vascularity  or  recent  deposit  exists  in  the  mem- 
brana  tympani,  notwithstanding  manifest  improvement  of  the  hear- 
ing, we  should  not  desist  from  employing  means  to  remove  it,  as 
these  cases  are  of  a  most  insidious  and  protracted  character.  When 
ulceration  exists,  we  should  touch  the  part  daily  with  a  solution  of 
lunar  caustic,  applied  with  a  fine  brush. 

In  all  the  inflammations  of  the  middle  and  external  ear,  the  secre- 
tion of  cerumen  is  arrested,  and  it  is  long  after  the  disease  has  been 
relieved,  that  the  cerumenous  glands  resume  their  healthy  functions, 
the  auditory  passage  remaining  dry  and  its  lining  scaly :  or  the  wax 
which  is  produced  being  insufficient  in  quantity,  of  a  very  dark  color, 
and  soon  becoming  hard  and  inspissated.  This  deficiency  of  ceru- 
men, which  is  but  a  symptom,  is  often  set  down  as  a  disease,  and 
various  applications,  such  as  ox-gall,  creasote,  glycerine,  &c.,  have 
been  recommended  to  restore  it.  I  find,  however,  that  nothing  pro- 
duces a  healthy  action  in  the  parts  so  soon,  while,  at  the  same  time, 
it  immediately  supplies  the  best  artificial  succedaneum,  as  the  soft 
brown  citrine  ointment,  applied  to  the  auditory  passage  in  a  melted 
state  with  a  soft  brush. 

The  following  case  afibrds  a  good  example  of  the  subacute  form  of 
the  disease,  of  the  inattention  paid  to  the  early  symptoms  of  deaf- 
ness by  practitioners  in  general,  and  the  efficacy  of  antiphlogistic 
treatment.  As  the  subject  of  this  case,  Mr.  S.,  then  aged  19,  was  a 
gentleman  of  very  great  intelligence,  I  give  the  history  of  his  case, 
as  far  as  possible,  in  the  words  of  the  narrative  with  which  he  has 
furnished  me  :  "  About  the  year  1836  I  felt  symptoms  of  deafness  in 
both  my  ears  for  the  first  time,  but  on  the  application  of  blisters 
these  symptoms  passed  away.     From  being  but  a  child  at  the  time, 

'  The  following  is  the  formula  for  the  tincture : — One  ounce  and  a  half  of  the  flowers 
to  a  pint  of  rectified  spirit  of  wine ;  macerate  for  fourteen  days  and  strain  ;  or,  of  the 
leaves,  the  same  quantity  infused  for  a  similar  period  in  proof  spirits.  In  prescribing 
these  I  usually  order  them  in  equal  proportions. 

Dr.  Neligan  says :  "  This  tincture  may  be  readily  prepared  by  percolation,  having 
previously  macerated  the  flowers  with  a  little  of  the  spirit  for  twenty-four  hours ;  or  it 
may  be  prepared  with  the  cut  and  bruised  root  in  the  proportion  of  ^ii.  of  the  root  to 
Oj.  of  rectified  spirit.    Dose,  f.  ^ss.  to  f.  ^ii."— -ilferfzriwes  and  their  Uses. 


250  SUBACUTE    MYRINGITIS. 

I  have  an  imperfect  recollection  of  tlie  peculiar  symptoms  of  my  case. 
Again,  in  1840,  I  became  quite  deaf  in  my  right  ear :  this  I  men- 
tioned to  our  family  physician,  but  for  some  time  he  treated  it  as  a 
joke,  telling  me  merely  that  I  was  idle  and  wished  for  some  holidays ; 
however,  on  my  frequently  asserting  that  I  really  was  deaf,  he  di- 
rected me  to  syringe  my  ear  night  and  morning,  and  afterwards  he 
dropped  some  liquid  into  it  which  he  prescribed  for  me,  but  he  did 
not  make  any  particular  examination  of  my  ear.  I  continued  to  fol- 
low his  advice  for  some  weeks,  but  without  any  beneficial  efi"ect.  I 
was  then  advised  to  get  some  rusty  bacon,  cut  it  into  small  shreds, 
and  put  one,  morning  and  evening,  into  my  ear, — but  with  no  better 
success.^  At  last  I  applied  a  blister  behind  my  ear,  and  kept  it 
open  for  six  months.  This  treatment,  which  may,  and  very  probably 
would,  as  experience  has  since  shown  me,  have  been  successful,  had 
it  been  resorted  to  in  the  first  instance,  was  then  of  no  avail.  On 
two  subsequent  occasions,  about  Christmas,  1841,  and  July,  1842,  I 
had  an  earache  in  that  ear,  and  the  only  application  which  gave  me 
relief  was  dropping  warm  laudanum  into  it.^  At  the  close  of  Sep- 
tember, 1845,  I  felt  my  left  ear  one  morning  as  if  it  were  stopped, 
and  perceived  a  buzzing  sound  in  it,  such  as  one  feels  on  applying  a 
sea-shell  to  it.  This  noise  was  increased  at  night  when  I  lay  in  bed ; 
it  then  resembled  a  constant  loud  hissing.  I  became  very  deaf,  and 
my  difiiculty  of  hearing  increased  daily ;  I  also  experienced  an  uneasy 
sensation,  and  a  feeling  of  stuffing,  in  this  ear,  but  no  pain." 

On  the  21st  of  November  following  I  first  saw  this  young  gentle- 
man. I  found,  in  addition  to  the  symptoms  already  described,  a 
bright  pink  hue  diffused  over  the  left  tympanal  membrane,  which, 
however,  had  not  lost  its  polish,  nor  become  opaque.  He  was  with 
difficulty  able  to  inflate  the  drum,  and  when  he  did  so,  the  stream  of 
air  caused  a  slight  squeeling  and  a  mucous  gurgling  in  the  middle 
ear.  The  external  meatus  on  both  sides  was  dry,  devoid  of  cerumen, 
and  somewhat  redder  than  natural.     The  throat  was  normal.     It  was 

*  This  is  a  very  popular  remedy  in  Ireland,  and  is  frequently  prescribed  by  medical 
practitioners.  In  cases  of  deafness  solely  the  result  of  a  deficiency  of  cerumen  (very 
rare  cases,  by  the  way)  it  is  innoxious,  and  may  be  effectual,  but  in  no  other  case  that  I 
am  avi^are  of  is  it  at  ail  applicable. 

2  Laudanum  dropped  into  the  ear  is  one  of  the  most  popular  remedies  for  the  ear- 
ache, and  in  many  instances  it  affords  relief.  I  do  not  object  to  its  application  as  a 
means  of  lessening  pain,  but  I  do  as  a  remedial  agent,  while  the  cause  of  the  pain  is  un- 
investigated, and  not  treated  according  to  the  established  rules  for  lessening  inflamma- 
tion, &c. 


SUBACUTE    MYEIIs^GITIS.  251 

evidently  a  case  of  subacute  inflammation  of  the  membrana  tympani, 
of  the  mucous  membrane  lining  the  ca^dty  of  the  drum,  and  the  Eu- 
stachian tube  :  with  mucous  engorgement  of  the  middle  ear.  Upon 
the  right  side  the  membrana  tympani  was  thickened  and  opaque,  and 
two  or  three  large  red  vessels  spread  over  its  surface,  but  the  air 
passed  up  with  facility.  Six  leeches  were  immediately  applied  to 
the  left  ear,  three  round  the  meatus,  and  three  in  front  of  the  tragus, 
and  warm  stupes  and  fomentations  prescribed. 

Upon  the  29th  his  symptoms  remained  unabated  and  the  appear- 
ances unaltered,  so  I  immediately  put  him  on  the  use  of  mercury ; 
and  at  the  same  time  a  repetition  of  the  leeches  round  the  meatus, 
and  the  application  of  blisters  over  the  mastoid  process,  was  had  re- 
course to.  As  soon  as  the  mouth  became  slightly  affected,  I  observed 
that  the  vascularity  of  the  right  ear — that  originally  affected — was 
very  much  lessened,  and  I  then  recommended  the  application  of 
leeches  and  bKsters  to  that  also ;  and  had  the  satisfaction  to  find, 
that  the  hearing  began  to  improve  gradually  on  this  as  well  as  on  the 
left  side. 

As  Mr.  S.  improved  daily  the  mercm-y  was  omitted,  and  he  com- 
menced the  use  of  bark  and  hydriodate  of  potash.  Towards  the  end 
of  December  he  was  so  much  improved  that  I  discontinued  my  at- 
tendance, and  r  lost  sight  of  him  for  a  short  time.  In  the  beginning 
of  January,  1846,  however,  he  again  applied  to  me :  worse  than  ever. 
The  weather  had  been  remarkably  damp  and  unfavorable ;  he  was 
much  exposed  to  its  influence,  and  had  caught  cold,  which,  to  use  his 
own  expression,  had  "pitched  in  his  ears."  He  was  then  so  deaf 
that  he  could  with  great  difficulty  understand  what  was  said  to  him, 
although  addressed  in  a  distinct  and  loud  voice.  The  vascularity 
had  returned  in  the  left,  and  partially  in  the  right  ear,  and  the 
mucous  engorgement  of  the  tympanal  ca\ities  was  more  manifest. 
The  same  course  had  to  be  pm'sued  as  on  the  former  occasion ;  he 
was  confined  to  the  house  for  a  month,  and  kept  under  the  gentle 
influence  of  mercury  for  the  last  three  weeks  of  that  time.  I  de- 
sired him  to  try  occasionally  to  press  the  air  into  the  drums,  particu- 
larly when  blowing  the  nose ;  and  as  the  inflammatory  condition  sub- 
sided he  was  enabled  to  do  this  with  greater  facility.  Each  time  the 
air  passed,  his  hearing  was  improved.  At  the  end  of  a  month  the 
mercury  was  discontinued  and  the  leeching  given  up.  Small  blisters 
were  kept  open  behind  the  ears,  and  the  use  of  bark  and  hydriodate 
of  potash  was  persisted  in  for  some  weeks  longer.     In  the  following 


252  SYPHILITIC    MYRINGITIS. 

November  all  trace  of  disease  had  been  removed  from  the  left  ear, 
and  tbe  tympanal  membrane  of  the  right  was  much  thinner,  and 
much  less  vascular  and  opaque,  than  when  I  first  saw  him  in  1845 ; 
— his  hearing  was  perfect  upon  the  left  side,  and  increased  on  the 
right  to  fourteen  inches.  He  has  remained  well  from  that  time  to  the 
date  of  the  publication  of  this  work. 

In  the  foregoing  case  we  have  a  good  example  in  the  right  ear, — 
which,  when  I  first  saw  it,  was  in  the  condition  of  chronic  inflamma- 
tion,— of  the  effects  of  neglect,  and  also  of  the  efficacy  of  the  mercu- 
rial and  antiphlogistic  treatment,  not  only  in  the  removal  of  recent 
disease,  but  in  the  improvement  of  an  affection  of  several  years' 
standing. 

I  could  enumerate  several  other  well-marked  cases  of  this  disease, 
were  it  necessary,  all  presenting  the  same  appearances,  and  cured 
by  the  same  means,  but  in  very  few  has  treatment  been  attended  with 
the  same  happy  results  in  an  ear  so  long  affected  as  in  this.  Gene- 
rally only  one  ear  is  affected  at  a  time,  but  sooner  or  later  the  other 
usually  becomes  engaged.  I  feel  convinced  that  many  cases  of  in- 
curable deafness  have  arisen  from  this  disease. 

In  the  treatment  of  the  malady,  the  efficacy  of  tobacco-smoke 
should  not  be  omitted.  Where  there  is  redness  and  relaxation  of  the 
mucous  membrane  of  the  throat  and  nose,  with  much  "  stuffing  in  the 
head,"  and  mucous  engorgement  of  the  middle  ear,  the  moderate  use 
of  tobacco-smoke  inhaled  from  a  good  cigar,  and  gently  puffed  out 
through  the  nose,  will  be  found  beneficial.  It  certainly  acts  as  a 
stimulant  and  astringent  on  the  surface  with  which  it  comes  in  con- 
tact, and  it  is  not  improbable  that  some  of  it  may  find  access  to  the 
cavitas  tympani.  I  understand  soldiers  are  in  the  habit  of  forcing 
tobacco-smoke  into  their  ears  when  they  become  deaf.  In  strumous 
myringitis,  and  also  in  chronic  or  subacute  inflammation  of  the  lin- 
ing of  the  tympanum,  tobacco-smoke  is  often  of  service. 

Syphilitic  Myringitis. — Although  practitioners  who  treat  syphilitic 
diseases  upon  a  large  scale  appear  to  be  aware  of  the  fact,  that  vene- 
real occasionally  causes  deafness,  I  cannot  find  any  authority  which 
has  noticed  the  disease  I  am  about  to  describe.  The  deafness  which 
sometimes  accompanies  the  secondary  form  of  syphilis  is  generally 
believed  to  be  caused  by  inflammation  and  ulceration  extending  from 
the  throat  through  the  Eustachian  trumpet  into  the  middle  ear ;  such 
may,  under  certain  circumstances,  no  doubt,  occur,  and  produce  de- 
structive inflammation  and  suppuration  in  this  cavity,  although  I  have 


SYPHILITIC    MYRINGITIS.  253 

never  seen  siicli  a  case  myself,  nor  have  I  met"  with  a  well-authenti- 
cated instance  of  it  recorded.  The  English  writers  upon  aural  dis- 
eases have  altogether  omitted  syphilitic  affections  of  the  ear,  as  have 
also  Kramer  and  most  of  the  continental  writers,  with  the  exception 
of  Lincke  and  Frank,  the  latter  of  whom  enumerates  two  forms, — 
the  first,  external  syphilitic  otitis,  in  which  secondary  ulcerations  oc- 
cur in  the  auditory  canal,  accompanied  by  other  well-determined  symp- 
toms of  the  disease ;  but  these  are  already  known  to  the  surgeon, 
they  resemble  ulcerations  on  the  margins  of  the  tarsal  cartilages,  and 
are  sometimes  the  consequences  of  rupia  upon  the  auricle,  in  the 
vicinity  of  the  meatus  (see  page  171).  Under  the  head  of  otitis 
interna,  he  describes  the  result  of  lues,  which,  he  says,  arises  either 
as  a  reflex  of  the  disease  in  the  ear  itself,  or  is  propagated  through 
the  Eustachian  tube  from  the  throat.  He  says  this  disease  is  accom- 
panied by  great  pain,  and  often  terminates  in  suppuration  of  the 
middle  ear,  destruction  of  the  tympanal  membrane,  and  caries  of  the 
temporal  bone.  It  is  evident,  however,  from  his  description,  that  the 
disease  of  which  he  speaks  is  the  ordinary  suppuration  of  the  cavity 
of  the  tympanum,  with  neglected  otorrhoea,  and  in  nowise  characte- 
rized by  any  peculiar  syphilitic  symptom. 

Lincke's  usual  accuracy  and  observation  seem  to  have  deserted  him 
when  writing  his  chapter  upon  "Otitis  Syphilitica;"  for,  while  the 
affection  now  under  consideration  seems  totally  to  have  escaped  obser- 
vation, he  has,  with  most  laborious  German  assiduity,  collected 
together  a  multiplicity  of  authorities  bearing  upon  the  subject  of  what 
are  supposed  to  be  syphilitic  diseases  of  the  ear,  but  not  one  of  which 
he  himself  has  verified.  Thus  he  enumerates  from  the  works  of  Cul- 
lerien  and  Plisson  chancres  both  on  the  auricle  and  in  the  meatus.  He 
also  gives  a  description  of  chancres,  "  if  they  arise  near  or  on  the 
membrana  tympani !"  but,  like  Frank,  his  descriptions  are  chiefly  in 
reference  to  the  syphilitic  otorrhoea,  the  result  of  inflammation  and 
ulceration  extending  from  the  throat  or  nose,  a  disease,  the  existence 
of  which  yet  remains  to  be  proved  by  original  observers,  not  system- 
makers  or  cyclopaedia-compilers. 

While  Lincke's  work  must  ever  remain  a  most  valuable  book  of 
reference,  it  is  high  time  for  those  who  "vvish  to  advance  the  science  of 
aural  surgery  to  cast  off  the  incubus  of  authority,  and  by  patient 
investigation  and  originality  of  observation  to  establish  facts.  Kra- 
mer deserves  much  more  credit  for  omitting  all  notice  of  an  affection 
which  it  is  evident  he  had  never  himself  observed,  than  those  writers, 


254  SYPHILITIC    MYRINGITIS. 

who,  with  equal  want  of  knowledge,  have  endeavored,  by  collecting 
out  of  a  variety  of  obscure  writers  some  ill-recorded  cases,  to  esta- 
blish an  untenable  theory. 

In  1835,  M.  Lallemand,  in  his  Clinical  Lectures  on  Syphilitic  Dis- 
eases, as  reported  by  Dr.  "Waters,  related  four  cases  of  syphilitic 
deafness  cured  by  anti-venereals.  (See  Medical  Times,  for  27th 
September.)  Were  medical  literature  to  be  searched  from  end  to 
end,  I  do  not  think  such  instances  of  unwarranted  assertion  and 
loose  writing  could  be  found.  The  state  of  the  membrana  tympani 
was  never  inspected,  nor  the  condition  of  the  middle  ear  explained, 
in  any  one  of  these  cases. 

The  disease  Avhich  I  am  about  to  describe  is  an  inflammation  of  a 
specific  character,  occurring  in  the  membranes  of  the  tympanal  ca- 
vity, but  chiefly  exhibited  in  the  external  membrane  of  the  drum.  All 
the  cases  I  have  seen  of  this  affection  occurred  in  young  men,  and 
generally  those  of  fair  complexions  and  blue  eyes,  who  had  had  pri- 
mary sores  upon  the  genitals  from  six  to  twelve  months  previously, 
which  'sores  were  of  rather  a  deceptive  character,  so  that  mercury 
was  seldom  given  in  the  first  instance,  at  least  in  a  legitimate  form. 
These  sores  were  usually  tedious  in  healing,  and  followed  by  papular 
eruptions  and  sore  throats,  for  vrhich  mercury  was,  in  most  of  the 
cases,  taken  irregularly.  Buboes  were  not  a  common  attendant,  nor 
had  iritis  ensued  in  any  of  the  instances  of  well-marked  venereal 
myringitis  which  fell  under  my  notice  ;  but,  generally  speaking,  erup- 
tions, copper-colored  blotches,  fissures  and  ulcers  of  the  tongue,  with 
loss  of  strength,  and  slight  nocturnal  pains,  existed  previous  to  the 
aural  affection,  which  should,  I  think,  be  ranked  as  a  tertiary  symp- 
tom. In  almost  every  case  which  I  have  witnessed,  the  disease 
appeared  suddenly,  as  an  eruption  was  fading  off;  in  two,  it  came  on 
at  a  later  period,  and  was  accompanied  by  loss  of  hair ;  in  most  it 
appeared  in  the  upper  or  middle  ranks  of  life.  In  some  cases  there 
is  at  first  a  sensation  of  fulness  in  the  head,  and  often  vertigo  upon 
stooping  or  rising  up  suddenly,  and  the  patients  have  usually  a  feel- 
ing of  fulness  within  the  ear ;  but  in  no  instance  have  I  seen  it  accom- 
panied by  acute  pain,  in  which  circumstances  it  resembles  the  sub- 
-  acute  form  of  inflammation  already  described,  and  is  therefore  placed 
as  a  subdivision  of  that  species ;  but  upon  inspection,  the  amount  of 
redness  and  vascularity  will  be  found  very  much  greater  than  the 
latter ;  and  in  this  consists  one  of  the  chief  characteristics  of  this 
disease,  that  Avhile  it  is  unaccompanied  by  local  pain,  as  in  the  sub- 


SYPHILITIC    MYRINGITIS.  255 

acute  inflammation,  the  membrana  tympani  will  be  found  to  present 
an  amount  of  redness  equal  to,  and  sometimes  exceeding,  tliat  seen 
in  acute  myringitis.  The  redness  has  generally,  however,  a  brownish 
hue  in  the  syphilitic  form,  which  is  not  observable  in  that  just  alluded 
to.  There  is  not,  at  first,  much  loss  of  polish,  but  in  a  short  time 
the  membvane  assumes  a  fuzzy  appearance.  The  auricle  and  meatus 
I  have  not  seen  affected  more  than  in  the  subacute  form ;  both  ears 
are  usually  attacked  at  the  same  time.  The  amount  of  deafness  is 
always  very  great,  and  is  the  symptom  that  first  attracts  the  patient's 
attention,  and  it  seldom  varies.  Tinnitus  is  not  usually  present,  but  in 
two  cases  which  I  possess  the  notes  of,  the  deafness  was  ushered  in  by 
a  very  loud  noise,  which  passed  away  after  a  few  days.  This  inflam- 
mation does  not  end  in  muco-purulent  discharge  from  the  tympanum, 
the  surface  of  the  membrana  tympani,  or  the  sides  of  the  auditory 
canal ;  nor  have  I  seen  lymph  efiused  upon  the  membrane,  as  in  the 
more  violent  and  painful  forms  of  otitis  ;  but  from  its  brownish-red 
color  in  the  very  early  stage,  from  a  yellowish  speckled  opacity,  which 
is  generally  observable  in  it  on  the  subsidence  of  the  redness,  an(;i 
from  the  intense  degree  of  thickening  and  dulness  which  were  present 
in  some  cases,  which  were  evidently  the  result  of  syphilitic  disease,  I 
am  inclined  to  think  that  lymph  is  largely  efi"used  between  the  laminae, 
or  upon  the  inner  surface  of  the  membrana  tympani.  Two  of  the 
worst  cases  of  non-congenital  deafness  I  ever  saw  appeared  to  have 
been  the  result  of  syphilitic  inflammation,  and  in  both  there  was 
great  thickening,  opacity,  and  insensibility  of  the  membrane.  I  am 
also  inclined  to  think  that  syphilis  has  played  a  more  extensive  part 
in  the  production  of  deafness  than  the  profession  is  aware  of. 

The  following  case  of  syphilitic  inflammation  of  both  tympanal 
membranes,  with  rapid  recovery  under  mercurial  treatment,  is  cha- 
racteristic of  the  afi'ection. 

Mr.  A.  B.,  aged  30,  had  a  doubtful-looking  sore  upon  the  penis, 
twelve  months  previous  to  my  seeing  him.  Considerable  doubt  was 
expressed  as  to  the  genuine  syphilitic  character  of  the  sore ;  but  it 
healed  under  local  treatment.  Some  months  subsequently  he  had  a 
bubo  in  the  right  groin,  and  a  small  abscess  also  formed  on  the  under 
side  of  the  iwethra  ;  he  then  rubbed  in  mercury,  and  was  confined  to 
the  recumbent  posture,  until  the  swelling  of  the  groin  had  completely 
subsided.  After  this  he  experienced  great  weakness  and  lassitude, 
and  sufi"ered  for  several  weeks  from  sore  throat.  These  symptoms 
were  relieved  by  removal  to  the  country ;  but  on  his  retm-n  to  town, 


256  SYPHILITIC    MYRINGITIS. 

an  eruption  appeared  extensively  on  the  genitals,  thighs,  and  abdomen, 
and  he  had  also  some  slight  deafness.  He  was  benefitted  by  the  use 
of  hydriodate  of  potash ;  but  the  eruption  came  and  went,  both  on 
its  original  seat  and  on  the  chest  and  extremities,  during  the  next  few 
weeks.  I  first  saw  him  with  Mr.  John  Evans,  in  the  middle  of  Octo- 
ber, 1847  ;  he  had  then  no  sore  throat,  but  a  fresh  crop  of  eruption, 
in  the  form  of  brownish  spots  interspersed  with  small  pimples,  had 
appeared  generally  over  the  back  and  the  outer  sides  of  the  arms. 
He  had  also  become  exceedingly  deaf,  hearing  the  watch  only  when 
pressed  against  the  auricle,  and  he  complained  of  a  sense  of  giddiness 
and  fulness  in  the  head,  but  had  no  pain  whatever  in  the  ears,  nor 
any  snuffing  in  the  nose.  He  stated,  that  his  deafness  had  occurred 
suddenly,  a  few  hours  after  rising  in  the  morning  some  days  before ; 
that  he  had  tinnitus  at  the  commencement,  but  that  it  had  now  nearly 
vanished.  Upon  inspection,  the  auditory  canal  was  found  dry,  and 
the  membrana  tympani  of  an  uniform  dark  brown-red  color,  so  that 
the  situation  of  the  hammer  bone  was  not  easily  recognisable.  There 
was  no  "ulceration  observable,  nor  any  alteration  in  the  plane  of  the 
membrane ;  but  the  light  was  not  reflected  from  it  in  the  ordinary 
manner,  thus  showing  that  it  had  lost  its  polish.  These  appearances 
were  nearly  the  same  upon  both  sides.  He  was  able  to  inflate  the 
drums  perfectly,  and  auscultation  afforded  no  evidence  either  of  con- 
traction of  the  audito-faucial  passages,  or  of  any  accumulation  of 
fluid  within  the  tympana. 

The  treatment  consisted  in  the  application  of  leeches  round  the 
meatus  every  second  day,  and  the  use  of  calomel  and  opium  in  small 
and  frequently  repeated  doses.  This  mode  of  administering  the  mine- 
ral disagreeing,  we  were  obliged  to  discontinue  it,  and  substitute 
inunction  in  its  stead.  The  deafness  and  the  appearance  in  the  ear 
remained  unaltered  until  the  morning  on  which  salivation  was  produced, 
and  then  hearing  was  restored  almost  miraculously,  and  the  next  day 
the  redness  and  vascularity  in  the  ears  had  almost  disappeared. 
Gentle  ptyalism  was  kept  up  for  some  days  longer.  He  has  not  since 
had  any  return  either  of  the  deafness  or  other  syphilitic  symptoms. 

I  attended  a  case  with  Mr.  Cusack  some  years  ago,  in  which  it  was 
found  necessary  to  keep  up  the  mercurial  action  for  above  a  fortnight, 
but  in  that  instance  the  disease  had  been  of  much  longer  standing ; 
I  also  treated  a  well-marked  case  in  consultation  with  Mr.  Mason,  in 
which  several  relapses  occurred,  just  as  we  often  observe  in  syphilitic 
iritis. 


SYPHILITIC    MYRINGITIS.  257 

Case  No.  4  in  the  Registry  presented  syphilitic  inflammation  of 
the  membrana  tympani  on  both  sides. 

P.  L.,  aged  30,  a  policeman,  with  fair  complexion,  light  hair  and 
eyes ;  has  complained  of  deafness,  unattended  mth  pain,  for  one 
month ;  says  he  had  a  primary  syphilitic  sore  about  three  months  ago, 
and  lately  suffered  from  sore  throat ;  has  slight  copper-colored  patches 
upon  the  skin  of  the  forehead,  but  does  not  exhibit  symptoms  of  any 
other  eruption.  He  has  ulceration  of  the  soft  palate,  a  deep  excava- 
tion, "with  a  yellowish  ash-colored  slough  coating  its  bottom,  existing 
on  each  side  of  the  uvula.  He  did  not  get  mercury  for  the  original 
sore.  The  deafness  came  on  in  both  ears  about  the  same  period,  and 
occurred  during  the  daytime. 

Left  Ear. — Meatus  dry,  polished,  of  a  gray  color,  and  totally 
devoid  of  cerumen.  The  tympanal  membrane  shows  an  exceedingly 
well-defined  subacute  inflammation ;  there  is  a  pinkish  hue,  like  that 
of  a  rose-leaf,  all  over  it,  but  it  still  preserves  its  polish,  and  has  not 
become  collapsed  or  altered  in  shape :  a  tolerably  well-marked  cres- 
centic  opacity  margins  its  inferior  attachment.  The  patient  can 
inflate  the  drum,  and  thereby  render  the  vascularity  of  its  external 
membrane  more  intense,  and  of  a  darker  red ;  he  has  a  singing  noise 
in  this  ear,  and  only  hears  the  watch  when  pressed  against  the  auricle. 

Right  Ear. — Meatus  paler,  more  polished  and  opaque  than  on  the 
left  side.  The  tympanal  membrane  is  redder,  and  also  somewhat 
collapsed,  so  that  the  malleus  projects  very  prominently.  Has  an 
intermitting  noise  in  character  like  that  experienced  when  a  conch- 
shell  is  held  to  the  ear.  Cannot  fully  inflate  the  drum  on  this  side, 
but  the  effort  to  do  so  renders  the  membrane  of  a  deeper  color. 
Cannot  hear  the  watch  on  this  side. 

A  pill  of  one  grain  of  calomel,  two  of  blue  pill,  and  a  quarter  of 
a  grain  of  opium,  was  ordered  to  be  taken  three  times  a  day. 

30th.  In  this  case  the  mercury  has  acted  fairly  and  legitimately, 
and  we  find  that  the  disease  for  which  it  was  administered  has  already 
given  way.  In  the  right  ear  the  pinkish  color  of  the  drum-head  is 
very  much  lessened,  the  polish  has  been  in  part  restored,  and  the  pa- 
tient says  that  the  singing  noise  has  greatly  decreased.  He  now 
hears  the  watch  when  applied  to  the  ear.  Upon  the  left  side  all  the 
symptoms  have  improved,  and  the  hearing  distance  has  increased 
about  two  inches.  If  we  apply  the  watch  to  the  ear  and  then  draw 
it  slowly  from  it,  the  deaf  person  will  be  able  to  catch  the  sound  (the 

17 


258  SYPHILITIC    MYRINGITIS. 

ear  appearing  to  retain  the  impression  of  the  ticking)  at  a  somewhat 
greater  distance  than  if  we  approached  the  watch  to  the  ear. 

The  mercury  was  lessened  to  one  pill  night  and  morning,  and  direc- 
tions were  given  to  the  patient  to  decrease  it  still  further  if  the  mouth 
became  sorer.  The  ulcers  upon  the  soft  palate,  which  have  assumed 
a  more  healthy  aspect  than  before,  were  brushed  over  with  a  strong 
solution  of  nitrate  of  silver. 

February  1st. — This  patient  is  greatly  improved  in  every  respect ; 
hearing  increased  on  both  sides.  Upon  the  left,  the  tympanal  mem- 
brane is  much  paler  than  at  the  time  of  the  last  examination,  and  the 
noise  completely  ceased  in  this  ear  upon  the  previous  day,  without 
the  man  being  conscious  of  any  crack  or  sudden  sound  at  the  time  of 
its  cessation.  Upon  the  right  side  the  membrane  has  improved  in 
color  and  gained  more  polish.  The  ulcers  in  the  throat  have  thrown 
off  their  sloughs,  and  present  a  healthy  appearance ;  the  mercurial 
action  upon  the  mouth  is  still  manifest.  The  dose  of  the  mineral  to 
be  decreased  to  one  pill  daily. 

5th. "  A  still  further  improvement  has  taken  place  since  last  report. 
Upon  the  right  side  the  membrane  is  yet  slightly  pinkish ;  the  hear- 
ing as  before.  Upon  the  left  side  the  membrane  has  greatly  improved, 
and  is  now  nearly  of  a  natural  color ;  hearing  distance  seven  inches ; 
throat  healthy ;  mercurial  action  still  manifest.  Ordered  four  grains 
of  hydriodate  of  potash  and  one  drop  of  tincture  of  iodine,  to  be 
taken  in  decoction  of  bark  three  times  daily. 

'9th.  General  health  and  appearance  much  improved.  Mercurial 
action  scarcely  perceptible  ;  but  the  gums  are  still  slightly  retracted 
beneath  the  lower  incisors,  and  exhibit  a  red,  pulpy  margin.  The 
ulceration  of  the  throat  has  quite  ceased,  and  the  cavity  upon  the  left 
side  is  nearly  filled  up.  He  says  his  hearing  is  completely  restored, 
but  the  noise  comes  on  occasionally  in  the  right  ear.  Upon  this  side 
there  is  some  secretion  of  cerumen  upon  the  posterior  surface  of  the 
meatus.  The  tympanal  membrane  is  still  slightly  pinkish,  but  bright, 
thin,  and  polished,  reflecting  the  light  from  its  lower  convex  portion. 
He  can  inflate  the  tympanum  with  facility,  and  upon  applying  the 
stethoscope  over  the  meatus,  while  the  patient  presses  the  air  into  the 
ear,  a  slight  gurgling  noise  can  be  perceived  as  it  reaches  the  cavity 
of  the  middle  ear,  which,  in  all  probability,  contains  a  quantity  of 
mucus,  exuded  from  its  lining  membrane  during  the  inflammatory 
process,  which,  there  can  be  little  doubt,  extended  to  it  and  to  the 
lining  of  the  Eustachian  tube, — parts  that  we  cannot  see, — as  well  as 


GOUTY    OTITIS.  259 

the  tympanal  membrane,  which  we  can  see.  On  the  left  side :  hear- 
ing distance  ten  inches ;  meatus  still  red,  shining,  and  devoid  of  ce- 
rumen ;  tympanal  membrane  opaque,  but  thin  and  polished ;  a  couple 
of  large  red  vessels  traverse  along  the  insertion  of  the  malleus.  The 
air  does  not  reach  the  cavity  of  the  middle  ear  so  well  as  upon  the 
right,  and  it  has  a  more  squeeling  sound,  probably  arising  from  the 
thickened  membrane  and  the  decreased  calibre  of  the  Eustachian 
tube.  Ordered  to  continue  the  iodide  of  potassium,  and  to  apply 
small  blisters  behind  the  ears  occasionally  for  the  next  fortnight. 

That  Grouty  Otitis  may  exist  I  have  no  doubt,  but  I  myself  have 
never  seen  a  well-marked  example  of  it ;  neither  have  I  yet  read  a 
description  of  that  disease  which  afforded  any  one  pathognomic  which 
could  be  relied  upon.  I  have,  at  page  170,  alluded  to  attacks  of 
gout  in  the  auricle  :  Dr.  Graves,  to  whose  authority  I  there  referred, 
gives  an  instance  of  deafness  attended  with  otorrhoea,  in  which  the 
patient's  hearing  was  always  improved  after  a  seizure  of  gout  in  the 
foot.  Several  continental  authors  mention  gout  as  a  cause  of  deaf- 
ness and  disease  of  the  ear  : — Dr.  Vering  of  Vienna,  in  1832  ;  Lincke 
in  1840 ;  and  Frank  in  1845  ;  but  they  are  chiefly  compilers,  whose 
writings  on  some  points  remind  one  of  the  variety  of  counts  intro- 
duced into  an  indictment  in  the  hope  that  some  one  of  them  may 
convict  the  prisoner.  Within  the  last  few  months  a  special  work  has 
appeared  on  the  subject, — that  referred  to  at  pages  60  and  222 ;  but 
I  cannot  discover  in  it  the  requisite  information,  as  the  symptoms  of 
the  different  forms  of  gouty  otitis  therein  detailed  are  common  •  to 
every  other  form  of  aural  inflammation.  The  author,  Mr.  Harvey, 
says  that  "furuncles  form  and  burst  in  the  muscles^  of  the  ears." 
Next  follows  otorrhoea,  which,  if  of  long  duration,  may  produce  po- 
lypous growths.  In  frequent  relapses  "  varicose  vessels  become  deve- 
loped on  the  membrana  tympani,"  and  when  the  disease  proves  fatal 
from  what  may  be  termed  cerebral  otorrhoea,  "  all  the  canals  are 
found  to  be  filled  with  purulent  matter,  as  well  also  the  cells  of  the 
mastoid  process,  the  bone  itself  being  in  a  state  of  caries."  Now, 
when  gout  seizes  upon  the  eye,  it  chiefly  afiects  the  sclerotic  and  the 
iris,  and  I  would  expect  from  analogy  that  where  it  was  seated  in  the 
ear,  its  manifestation  would  be  in  the  fibrous  layer  of  the  membrana 
tympani,  in  the  form  of  acute  myringitis,  like  that  seen  in  rheumatic 
cases. 

'  German  writers  often  style  the  auricle  the  ohrmuschel,  from  its  likeness  to  a  muscle- 
shell  or  conch. 


260  STRUMOUS    MYEINGITIS. 

Some  time  ago  Mr.  Toynbee  publislied  a  small  tract,  with  the  at- 
tractive title  of  "  The  Pathology  and  Treatment  of  the  Deafness 
attendant  upon  old  Age,"  in  which  the  author  successfully  combats 
the  conclusion  to  which  medical  men  have  arrived,  that  deafness  "  de- 
pends upon  a  gradual  and  natural  decay  of  the  powers  of  the  organ 
of  hearing,"  and  that  it  must  in  consequence  be  endured  as  a  disease 
entirely  beyond  human  control.  And  the  result  of  the  author's 
experience  tends  to  show  that  the  decline  of  audition  "  is  dependent 
upon  the  influences  to  which  aged  persons  are  frequently  subjected  : 
namely,  the  prolonged  stay  in  warm  rooms,  the  avoidance  of  the  open 
air,  the  cessation  from  bodily  exercise,  the  want  of  attention  to  diet, 
and  to  the  healthy  performance  of  the  functions  of  the  skin."  In 
support  of  this  view,  Mr.  Toynbee  has  given  the  dissection  of  eighteern 
cases,  a  portion  of  those  already  enumerated  at  page  116 ;  and  the 
results  obtained  were  thickening  of  the  mucous  lining  of  the  tympanic 
cavity,  and  also  of  the  membrana  tympani,  with  the  existence  of 
bands  of  adhesion  connecting  together  the  various  parts  contained 
within  "the  former.  These  evidences  of  previous  inflammation  are, 
however,  but  what  might  be  expected  in  the  post  mortem  examina- 
tion of  any  of  the  mucous  or  serous  cavities  in  aged  persons,  and  the 
condition  of  the  ears  in  those  dissections  is  similar  to  what  the  same 
author  has  shown  is  the  chief  cause  of  deafness  in  persons  at  any 
period  of  life. 

STRUMOUS   MYRINGITIS. 

I  have  had  some  difficulty  in  determining  whether  to  place  the 
following  disease  among  the  affections  of  the  cavity  of  the  tympanum 
or  the  membrana  tympani,  for,  its  seat  being  in  the  mucous  layer  of 
the  latter  structure,  it  is  manifest  that  it  must,  sooner  or  later,  spread 
over  the  whole  cavitas  tympani,  and  is  consequently  common  to  both. 
As,  however,  the  visible  signs  of  the  disease  are  most  apparent  on 
the  membrana  tympani,  I  have  classed  it  along  with  the  afi"ections  of 
that  part. 

This  is  a  frequent  afl"ection  in  young  persons,  and,  I  believe,  a  very 
constant  cause  of  deafness  in  after  life.  Its  subjects  are  usually  from 
five  to  fifteen  or  sixteen  years  of  age,  but  it  may  appear  at  a  much 
later  period.  It  chiefly  attacks  the  light-haired,  fair-skinned,  blue- 
eyed,  and  those  who  exhibit  well-marked  evidences  of  a  scrofulous 
constitution.  Its  first  symptom  is  that  of  deafness,  generally  attri- 
buted to  inattention :  scarcely  a  fortnight  passes  that  I  do  not  see  a 


STRUMOUS    MYRINGITIS.  261 

boy  or  a  girl,  from  ten  to  fifteen  years  of  age,  from  some  of  the  public 
schools,  who,  having  been  deaf  for  two  or  three  months  previous,  had 
been  constantly  reprimanded  for  inattention.  If  the  relations  are 
asked  why  they  did  not  take  advice  for  the  child  before,  the  general 
answer  is,  "We  thought  it  was  only  a  cold,  and  would  not  signify." 
The  auditory  passage  is  usually  dry,  but  seldom  red.  The  tym- 
panal membrane  will  be  found  of  an  uniform  pinkish  hue,  but  without 
either  thickening  or  opacity,  at  least  in  the  early  stages.  This  color, 
which  is  somewhat  the  tint  of  pink  blotting-paper,  appears  to  be 
seated  in  the  mucous  layer,  and  shines  through  the  other  lamina  of 
the  membrane,  which  still  preserve  their  polish  and  transparency. 
There  is  generally  mucous  engorgement  of  the  cavity  of  the  tympa- 
num, with  thickening  and  increased  redness  of  the  faucial  mucous 
membrane, — a  condition  which,  there  can  be  little  doubt,  extends 
through  the  lining  of  the  Eustachian  tube  into  the  middle  ear.  It  is, 
generally  speaking,  a  painless  disease,  and  but  seldom  accompanied 
by  tinnitus  in  the  first  instance  ;  occasional  crackling  sensations,  gurg- 
lings, and  loud  reports,  are  felt  in  the  ear,  and  sometimes  temporary 
relief  is  experienced  therefrom.  Catarrh,  stuffing  in  the  nose  and 
frontal  sinus,  and  great  liability  to  "  cold  in  the  head,"  are  not  un- 
usual symptoms,  or  rather  attendants ;  there  is  no  pain  on  pressure 
in  or  about  the  ear,  the  throat,  the  mouth,  or  the  Eustachian  tube. 
Strumous  affections  of  the  eyes  are  not  an  unfrequent  complication, 
and  these,  particularly  corneitis,  which  it  very  much  resembles,  and 
also  strumous  ophthalmia,  sometimes  alternate  with  the  affections  of 
the  ear,  as  shall  be  further  explained  in  this  chapter.  Enlargement 
of  the  tonsils  is  a  very  frequent  accompaniment;  and  glandular 
swellings  about  the  neck  not  an  uncommon  appearance  in  such  cases. 
The  amount  of  deafness  varies  from  a  hearing  distance  of  eight  or 
ten  inches  to  total  inability  to  hear  a  watch  applied  to  any  part  of 
the  head,  or  held  between  the  teeth,  or  even  to  hear  what  is  said  in 
a  loud  and  distinct  voice ;  and,  generally  speaking,  the  amount  of 
redness  and  vascularity  presented  in  the  membrane  of  the  drum  is  in 
the  ratio  of  the  amount  of  deafness  ;  but  the  latter  is  very  variable, 
and  would,  in  many  instances,  appear  to  be  influenced  by  the  state 
of  the  atmosphere, — being  greatest  in  damp,  moist  weather.  In  some 
cases  the  redness  assumes  a  dark,  damask-rose  color,  and  then  we 
may  generally  rest  satisfied  that  the  entire  of  the  middle  ear  is  en- 
gaged. Simple  mucous  discharge  occurs  occasionally,  and  purulent 
otorrhoea  succeeds  in  the  more  aggravated  cases,  as  the  disease  ad- 


262  STRUMOUS    MYRINGITIS. 

varices,  but  it  need  not  present  at  any  period  of  the  affection.  The 
constitution  is  generally  below  the  standard  of  health ;  the  patient  is 
usually  pale,  languid,  and  inactive,  with,  perhaps,  slight  loss  of  appe- 
tite, and  some  dryness  of  the  skin. 

This  form  of  myringitis  is  very  liable  both  to  relapses  and  returns, 
and  of  this  latter  circumstance  the  patient  or  the  friends  should  be 
always  informed.  When  once  a  child  has  had  this  complaint,  the 
slightest  exposure  to  cold  may  reinduce  it. 

The  treatment  in  this  disease  should  be  chiefly  directed  to  improve 
the  condition  of  the  constitution,  and  I  know  nothing  better  for  effect- 
ing this  object  than  the  use  of  bark  in  its  various  preparations,  con- 
joined with  iodide  or  bromide  of  potassium,  and,  when  the  inflamma- 
tion is  of  a  more  active  character,  the  bichloride  of  mercury.  In 
the  advanced  stages,  and  where  there  is  much  constitutional  taint 
evident,  with  enlargement  of  the  cervical  glands,  &c.,  the  oleum 
jecoris  will  be  found  most  effectual ;  but  whichever  of  these  may  be 
employed,  it  should  be  steadily  persisted  in  for  a  length  of  time. 
This  is  "a  slow  and  tedious  disease,  lasting,  even  in  the  most  favorable 
cases,  for  months,  and  being  liable  to  relapse,  patients  should  be  care- 
fully watched,  and  their  ears  examined  at  least  once  a  week,  while 
any  trace  of  inflammation  remains.  A  dry,  pure,  country  air,  and  a 
residence  by  the  sea-shore  in  summer,  will  always  be  found  beneficial ; 
but,  as  far  as  my  experience  extends,  I  have  always  found  bathing  in 
the  open  sea  injurious.  The  warm  bath  occasionally,  appears  to  be 
of  use.  As  in  cases  of  strumous  ophthalmia,  so  in  scrofulous  myrin- 
gitis, a  leech  or  two  may  sometimes  be  required,  although  depletion 
is  not  generally  indicated. 

As  the  tongue  is  usually  white  and  clammy,  and  the  dejections 
often  vitiated,  small  doses  of  chalk  and  mercury,  combined  with  rhu- 
barb and  columba,  given  as  alteratives  every  second  or  third  night, 
will  assist  our  other  means.  The  diet  should  be  light  and  highly 
nutritious,  while  all  acid  fruits,  pickles,  and  ill-boiled  or  stale  vegeta- 
bles, even  made  dishes  and  pastry,  should  be  avoided.  Constant 
open  air  exercise  during  the  fine  part  of  the  day  is  very  necessary ; 
and  when  the  weather  is  at  all  harsh,  cold,  or  damp,  a  light  covering 
should  be  worn  over  the  ears,  or  small  bits  of  cotton  laid  in  the  con- 
chas ;  but  in  the  house,  or  in  warm  weather,  these  precautions  are 
unnecessary ;  neither  do  I  believe  it  at  all  efiicacious  to  keep  the  head 
warmer  than  under  ordinary  circumstances. 

Counter-irritation  will  be  found  most  effectual,  and  the  vesicating 


STRUMOUS    MYRINGITIS.  263 

liniments  more  efficacious  than  the  ordinary  blistering.  The  strong 
tincture  of  iodine,  acetum  lyttse,  or  croton  oil  and  acetic  acid  con- 
joined with  the  spirit  of  turpentine,  oil  of  rosemary  and  soap  liniment, 
form  very  useful  applications.  This  latter  liniment  should  be  rubbed 
over  the  mastoid  process,  and  lower  down,  as  far  as  the  angle  of  the 
jaw,  once  or  twice  a  day,  until  a  slight  vesicular  rash  is  produced, 
when  its  use  ought  to  be  discontinued  until  the  redness  has  disap- 
peared, when  it  may  be  reapplied  as  before.  This  irritation  should 
be  kept  up  for  a  couple  of  months  at  least,  varying  the  application  as 
the  parts  become  accustomed  to  any  particular  substance.  Whatever 
is  used,  great  care  should  be  taken  that  it  does  not  spread  over  the 
back  of  the  auricle,  which  is  very  likely  to  become  inflamed  and 
greatly  swollen  by  it. 

This  is  one  of  the  diseases  in  which  catheterism  of  the  Eustachian 
tube  is  sometimes  necessary,  but,  I  believe,  not  so  often  as  is  gene- 
rally resorted  to.  When  the  patient  himself  can  readily  pass  a 
stream  of  air  into  the  drum,  by  making  a  forced  expiration,  whilst 
we  apply  our  ear,  or  a  stethoscope,  to  his  external  ear,  so  that  we 
can  distinctly  perceive  the  full  and  natural  inflation  of  the  membrane, 
the  introduction  of  a  catheter,  and  the  pressure  of  a  stream  of  cold 
air,  I  believe,  to  be  not  only  unnecessary,  but  injurious.  In  cases, 
however,  where  mucus  has  collected  in  the  cavitas  tympani,  cathe- 
terism may  be  resorted  to  occasionally,  and  even  warm  water,  or  some 
bland  fluid,  might  be  thrown  up  by  means  of  a  syringe,  although  I 
have  my  doubts  as  to  the  quantity  of  any  fluid  which  can  be  thus 
driven  into  the  tympanum,  in  order  to  wash  out  mucus,  pus,  blood, 
or  other  extraneous  substances.  As  I  do  not  believe  that  the  en- 
larged tonsils  which  often  accompany  this  disease — as  they  do  other 
strumous  affections — are  the  cause  of  the  deafness  and  the  inflamma- 
tion manifest  in  the  drum  and  its  membranes,  I  cannot  recommend 
their  removal,  as  has  been  proposed,  and  acted  on  by  others ;  but  the 
application  of  a  strong  solution  of  nitrate  of  silver  to  the  back  of  the 
throat  and  fauces,  and  particularly  towards  the  mouth  of  the  Eusta- 
chian tube,  by  means  of  a  piece  of  lint  attached  to  the  end  of  an 
aneurism  needle,  and  applied  as  far  up  as  possible  behind  the  pillars 
of  the  soft  palate,  will  be  attended  with  beneficial  results  ;^  and  the 

'[The  application  of  the  caustic  sohition  in  the  ordinary  way,  to  the  back  of  the 
throat  and  fauces,  always  produces  such  spasmodic  action  of  the  soft  palate,  that  the 
application  very  seldom  comes  in  contact  with  the  mouth  of  the  Eustachian  tube.  The 
following  mode  of  making  the  application  will  be  found  to  effect  it  better  than  even 


264  STRUMOUS    MYRINGITIS. 

use  of  astringent  gargles  should  be  persevered  in  during  the  continu- 
ance of  the  throat  affection.  If  otorrhoea  ensues^  is  to  be  treated  as 
I  have  recommended  in  the  chapter  upon  that  subject. 

No.  12  in  the  Registry  is  a  case  of  subacute  strumous  myringitis. 

M.  M.,  aged  16,  a  male. — It  is  quite  manifest,  from  the  way  in 
which  he  speaks,  that  this  boy  has  been  deaf  a  long  time.  His  utter- 
ance is  indistinct ;  there  is  a  sort  of  whistling  sound  in  his  speech,  as 
if  he  sipped  in  the  air,  and  then  blew  it  out  through  his  nose ;  his 
voice  is  hoarse  and  insonorous,  and  he  labors  under  that  peculiarity 
denominated,  though  incorrectly,  speaking  through  the  nose ;  the 
tonsils  are  not  enlarged ;  the  throat  is  normal,  with  the  exception  of 
a  slight  elongation  of  the  uvula,  but  which  is  quite  insufficient  to  ac- 
count for  the  peculiarity  of  his  speech ;  and  the  nose,  as  far  as  we 
can  ascertain,  does  not  exhibit  any  congenital  peculiarity  or  acquired 
disease.  This  boy  says  he  has  been  deaf  since  childhood ;  in  fact,  he 
never  remembers  hearing  well ;  he  has  had  occasional  slight  pains  in 
both  ears,  but  they  never  amounted  to  any  degree  of  intensity  ;  never 
had  a  discharge  from  either  ear,  but  suffers  from  noise  in  the  left. 
His  amount  of  hearing  varies  considerably  from  time  to  time,  and  is 
much  decreased  whenever  he  catches  cold. 

Right  side. — Hearing  distance  three  inches.  Auricle  and  meatus 
normal ;  tympanal  membrane  white,  thickened,  opaque,  and  slightly 
collapsed,  or  pressed  inwards  from  its  natural  curvature ;  its  lower 
edge  vascular.  He  cannot  inflate  his  drum ;  but  the  attempt  to  do 
so  increases  the  inferior  vascular  crescent,  and  causes  several  large 
red  vessels  to  appear  upon  the  upper  half  of  the  membrane. 

Left  side. — Only  hears  on  touching.  Membrana  tympani  exhibits 
a  uniform  pinkish  color,  somewhat  resembling  the  hue  of  a  rose-leaf ; 

that  recommended  by  Mr.  Wilde.  It  is,  to  depress  the  tongue  well  with  the  handle  of 
a  tablespoon,  having  the  concave  surface  of  it  looking  up  towards  the  roof  of  the 
mouth — then  take  the  ordinary  whalebone  probang,  used  for  cauterizing  the  throat,  and 
charging  the  sponge  on  the  end  with  the  solution ;  pass  the  instrument,  with  its  curve 
looking  to  the  right  or  left,  according  to  the  ear  affected,  along  the  handle  of  the  spoon, 
until  it  reaches  the  posterior  wall  of  the  pharynx;  then  suddenly  turn  it  up  vertical,  or 
nearly  so,  and  at  the  same  time  depress  the  hand  holding  the  spoon.  This  last  ma- 
noeuvre will  cause  the  end  of  the  spoon  to  act  as  a  lever  on  the  probang,  and  force  the 
sponge  up  behind  the  soft  palate,  whose  muscles,  with  those  of  the  jpharynx,  will  then 
be  throvi^n  into  spasmodic  action,  and  will  force  the  sponge,  by  the  addition  of  a 
little  lateral  pressure  on  the  probang,  close  to  the  orifice  of  the  Eustachian  tube.  This 
contraction  of  these  muscles  will  serve  the  additional  purposes  of,  perhaps,  dilating  the 
orifice  of  the  tube,  and  diffusing  by  tlieir  pressure  on  the  sponge  the  caustic  solution. — 
A.H.] 


OTITIS    IN    CONNEXION    WITH    OPHTHALMIA.  265 

the  tliickening  and  deposit  has  not  yet  taken  place.  To  introduce 
an  instrument  into  the  Eustachian  tube,  and  force  fluid  or  gaseous 
bodies  into  the  middle  ear,  would,  I  believe,  in  all  such  cases,  be  of 
little  avail  until  we  subdue  the  local  inflammation,  and  correct  the 
constitutional  tendency  to  its  return.  The  treatment  consisted  in 
slight  local  depletion  frequently  repeated,  long-continued  counter- 
irritation  over  the  mastoid  process,  and  the  eshibition  of  such  inter- 
nal remedies  as  we  know  by  experience,  from  the  diseases  of  analo- 
gous organs,  improve  the  constitution,  and  tend  to  correct  the 
tendency  of  disorganizing  inflammation,  such  as  the  oxymuriate  of 
mercury  and  bark,  the  preparations  of  iodine  and  potassium,  cod- 
liver  oil,  &c. 

OTITIS  IN  CONNEXION  WITH  OPHTHALMIA. 

The  following  cases  are  typical  of  a  form  of  strumous  inflammation 
of  the  ear  with  which  I  have  been  long  familiar.  It  sometimes  co- 
exists with,  sometimes  alternates  with,  the  ocular  disease.  What  is 
termed  strumous  ophthalmia,  and  also  corneitis,  are  the  forms  which 
the  eye  afiection  assumes.  Occasionally  it  is  that  of  choroido -iritis. 
We  often  see  the  patient  laboring  under  the  disease  of  the  eye  in  the 
spring  and  early  summer,  and  that  of  the  ear  in  autumn  and  winter. 
Both  seem  to  be  contingent  on  the  same  constitutional  diathesis,  but 
the  aural  afiection  being  generally  painless,  and  the  part  in  which  it 
is  seated  being  concealed  from  view,  it  attracts  little  attention,  or  it 
is  attributed  to  stupidity.  Unhappily,  in  these  cases  the  mischief 
has  been  done :  the  thickening  and  deposit  in  the  membrana  tympani 
have  already  taken  place  ;  the  inflammatory  action  has  subsided  ;  we 
now  only  witness  its  results,  and  treatment  will  avail  but  Httle.  Im- 
provement of  the  constitutional  health,  and  placing  the  patient  in  the 
most  advantageous  circumstances,  may  possibly  in  time  produce  so 
much  absorption  as  will  give  a  moderate  increase  of  hearing.  I  sup- 
pose these  cases  belong  to  that  class  which  medical  practitioners,  not 
examining  with  the  speculum,  and,  consequently,  not  knowing  what 
is  going  forward,  were  heretofore  in  the  habit  of  telling  patients  or 
their  friends  "to  let  alone,  and  in  time  they  would  grow  out  of  it." 
if  we  look  into  the  statistics  of  deaf-dumbness  for  difierent  countries 
in  Europe  and  America — and  the  same  remark  holds  good  with  re- 
spect to  the  investigations  instituted  in  Ireland  on  the  same  subject — 
we  shall  find,  among  the  causes  of  acquired  muteism,  "  diseases  of 
the  eyes  "  frequently  recorded.     Now,  as  we  cannot  suppose  that 


266         OTITIS    IN    CONNEXION    WITH    OPHTHALMIA. 

diseases  of  the  organs  of  vision  could  of  themselves  produce  total 
deafness,  leading  to  complete  loss  of  speech,  we  are  forced  to  the 
conclusion,  that  with  the  ophthalmic  disease  co-existed  some  insidious 
aural  affection  such  as  I  have  described,  and  so  intense  as  to  produce 
deafness,  and,  in  very  young  persons,  consequent  loss  of  speech.  It 
generally  occurs  at  from  five  to  fifteen  years  of  age  ;  but,  whether  it 
is  owing  to  metastasis  of  the  morbid  action  from  the  eye  to  the  ear, 
or  the  same  strumous  diathesis  inducing  the  affection  in  the  tympa- 
num, I  cannot  say. 

No.  26  in  Registry. — H.  M.,  a  female,  aged  16,  with  hazel  eyes, 
yellowish  hair,  large  projecting  mouth,  freckled  skin,  glandular  swell- 
ings of  the  neck,  and  other  manifestations  of  struma ;  has  been  deaf 
for  several  weeks.  There  is  an  opacity  of  the  cornea  on  both  sides, 
arising  from  ophthalmia,  for  which  she  was  treated  at  the  Institution 
some  years  ago.  She  had  also  strabismus  of  the  left  eye,  for  which 
she  was  successfully  operated  on  at  twelve  years  of  age.  Left  side. — 
Hearing  distance  four  inches ;  membrana  tympani  opaque,  densely 
white,  and  collapsed,  a  few  red  vessels  course  along  the  handle  of  the 
malleus;  tinnitus.  Right  side. — Hearing  distance  two  inches  ;  mem- 
brana tympani  opaque,  and  of  a  skim-milk  color  ;  tinnitus.  She  never 
suffered  from  pain ;  never  had  any  discharge  from  either  ear ;  throat 
natural;  tonsils  not  enlarged.  Ordered  cod-liver  oil,  and  to  have 
the  mastoid  region  painted  with  strong  tincture  of  iodine  daily. 

No  27  in  Registry. — A.  S.,  a  female,  aged  12,  with  dark  auburn 
hair,  fair  complexion,  and  hazel  eyes,  suffered  from  pain,  redness, 
and  intolerance  of  light  in  both  eyes  some  years  ago ;  traces  of  the 
affection  still  exist  in  the  nebulous  condition  of  both  cornese,  and  she 
bears  the  marks  of  glandular  enlargement ;  has  been  deaf  five  years  ; 
disease  came  on  with  pain  and  slight  discharge  from  both  ears ;  the 
discharge  has  ceased  for  some  time.  Right  side. — Meatus  natural ; 
membrana  tympani  thickened,  opaque,  and  of  a  brownish  color,  pre- 
senting the  appearance  of  crumpled  parchment;  hearing  distance 
scarcely  half  an  inch.  Left  side. — Membrana  tympani  devoid  of 
polish,  and  of  a  brownish-red  hue,  with  a  crescent-shaped  vascularity 
at  its  inferior  edge ;  the  disease  on  this  side  is  evidently  of  a  more 
recent  date  ;  hearing  distance  one  inch.  She  states  that  her  hearing 
is  always  better  in  the  spring  and  summer,  when  the  eyes  are  usually 
affected.  Ordered  oxymuriate  of  mercury,  with  bark  and  counter- 
irritation  behind  the  ear. 

Master  B.,  aged  ten  years  and  a  half,  consulted  me  during  the  past 


OTITIS    IN    CONNEXION    WITH    OPHTHALMIA.  267 

montli  on  accoimt  of  deafness,  so  complete  as  to  require  the  use  of 
writing  in  communicating  with  him.  He  is  of  a  strumous  family, 
several  members  of  which  have  been  deaf.  He  had  a  brother  who 
lived  to  four  years  of  age,  but  never  exhibited  consciousness,  seldom 
moved,  never  spoke,  did  not  appear  to  hear,  scarcely  to  see,  and  was 
to  all  appearance  idiotic.  Master  B.  had  convulsions  at  three  months 
old,  and  again  when  three  years  of  age ;  he,  however,  grew  up  to  be 
a  stout,  healthy  boy,  intelligent,  and  with  all  his  faculties  perfect. 
He  is  well  made,  has  blue  eyes,  and  rather  light  hair.  In  June,  1851, 
he  was  attacked  with  severe  ophthalmia,  which  lasted  about  six  weeks, 
in  the  left  eye.  The  disease  was  painless,  but  caused  intolerance  of 
light,  and  was  characterized  by  redness  of  the  globe,  lachrymation, 
and  great  indistinctness  of  vision.  He  was  then  seized  with  hooping- 
cough,  and  after  the  interval  of  a  month  the  right  eye  became  affected 
similarly  to  that  on  the  left  side.  During  the  winter  his  eyes  got  well, 
with  the  exception  of  an  opacity  on  the  right  cornea  ;  and  in  spring 
it  was  remarked  that  his  hearing  had  become  defective,  and  gradually 
lessened  up  to  November  last,  when  it  failed  altogether.  He  cannot 
hear  at  all,  even  by  shouting  into  his  left  ear ;  but,  when  his  mother 
speaks  to  him,  by  holding  her  mouth  to  the  right  auricle,  he  is  able 
to  distinguish  what  is  said.  His  voice  is  beginning  to  be  af- 
fected ;  it  has  lost  its  intonation,  has  become  nasal,  and  with  that  sip- 
ping character — as  if  drawn  in  through  the  closed  teeth — characte- 
ristic of  total  deafness,  which  I  have  described  at  page  89.  He  is  not 
conscious  of  the  ordinary  street  noises ;  he  does  not  complain  of  tin- 
nitus. Within  the  last  two  months  he  has  become  very  nervous, 
starting  up  in  his  sleep  without  any  apparent  cause,  especially  if  he 
awakes  and  does  not  find  a  light  in  his  room, — although  this  does  not 
seem  to  arise  from  the  usual  feeling  which  some  children  have  on  that 
subject.  Latterly  some  unsteadiness  of  gait  has  been  remarked ;  and 
.there  is  a  more  than  usually  frequent  desire  to  urinate,  especially 
after  lying  down. 

The  auricles  are  normal,  as  also  the  external  apertures  of  his  ears, 
although  the  latter  are  dry  and  devoid  of  cerumen.  The  membranas 
tympanorum  nearly  the  same  on  both  sides ;  are  very  much  altered 
from  the  natural  character ;  have  lost  their  transparency,  polish, 
and  curvature,  being  now  white,  thickened,  opaque,  and  slightly  col- 
lapsed. There  is  still  some  vascularity  around  the  tubercle  and  han- 
dle of  the  malleus,  the  result  of  previous  inflammation,  with  lymphy 
deposit  in  the  membrane.     All  that  can  be  learned  of  the  state  of 


268   TYPHOID   INFLAMMATIONS    OF    MEMBEANA    TYMPANI. 

the  cavitas  tympani  is,  that  it  is  unsusceptible  of  inflation  upon  the 
right  side,  and  scarcely  admits  any  air  upon  the  left ;  but  that  the  in- 
flammatory action,  which  has  left  such  manifest  traces  in  the  external 
membrane,  must  have  extended  over  the  tympanum,  and  possibly  into 
the  labyrinth,  there  can  be  little  doubt.  From  this  boy's  hereditary 
tendency,  his  slight  irregularity  of  gait,  the  nervous  startings  at  night 
— so  common  to  partially  deaf  people — and  the  tendency  to  frequent 
action  of  the  bladder,  it  is  not  unlikely  that  his  brain  and  spinal  mar- 
row may  be  engaged,  though  in  what  manner  it  is  difiicult  to  deter- 
mine. The  prognosis  is  not  favorable  to  a  recovery  of  hearing,  yet 
it  is  not  altogether  hopeless,  and  the  constitutional  symptoms  may 
possibly  be  grown  out  of.  The  treatment  recommended  consisted  in 
long-continued  counter-irritation  behind  the  ears  and  round  the  nape 
of  the  neck,  with  the  use  of  iodine  in  minute  doses,  taken  in  the  form 
of  a  mineral  water. 

In  cases  of  this  nature,  the  patient  should  be  encouraged  to  speak 
as  much  as  possible,  and  on  no  account  allowed  to  employ  signs  or 
finger-writing.  He  should  be  spoken  to  in  a  clear,  distinct  tone  of 
voice,  not  too  loud,  and  the  mouth  removed  from  his  ear  gradually 
day  by  day,  so  as,  if  possible,  to  educate  the  sense  and  increase  the 
hearing  distance ;  he  should  also  be  made  to  read  aloud  every  day. 
The  company  of  persons  of  his  own  age  will  be  advisable,  pro- 
vided they  are  not  allowed  to  resort  to  signs  in  communicating  with 
him ;  and  his  mind  should  be  engaged  with  some  pleasing,  healthful 
occupation. 

The  further  treatment — medical,  moral,  and  educational — of  the 
partially  deaf,  either  congenital  or  acquired,  will  be  considered  in  the 
chapter  upon  Deaf-dumbness. 

TYPHOID   AND   EXANTHEMATOUS   INFLAMMATIONS   OF  THE   MEMBRANA 

TYMPANI. 

In  the  otitis  accompanying  scarlatina,  measles,  and  small-pox,  I 
believe,  as  I  have  already  stated,  that  the  disease  either  commences 
in  the  mucous  lining  of  the  middle  ear,  or  spreads  into  the  cavity 
from  the  mouth  and  fauces  through  the  Eustachian  tube.  Sooner  or 
later,  however,  the  membrana  tympani  becomes  engaged,  and  is  rup- 
tured either  by  ulceration  or  from  the  pressure  of  the  contents  of  the 
tympanum,  and  otorrhoea,  with  its  long  and  varied  train  of  conse- 
quences, ensues.     This  form  of  inflammation  is  therefore  considered 


TYPHOID    INFLAMMATIONS    OF   MEMBRANA    TYMPANI.    269 

under  the  head  of  diseases  of  the  cavitas  tympani.  Moreover,  I  am 
not  at  present  able  to  state  from  personal  knowledge  what  are  the 
pecuHarities  of  the  inflammation  which  precedes  the  discharge  in  those 
cases ;  as,  although  of  very  common  occurrence,  the  practitioner  in 
aural  surgery  does  not  in  general  see  them  till  long  after  their  first 
appearance, — seldom,  indeed,  till  the  disease  becomes  chronic,  and 
complicated  with  polypus ;  or  often  not  till  long  after  ulceration  has 
destroyed  the  membrane,  the  ossiculse  have  been  discharged,  and  other 
irreparable  mischief  has  occurred.  During  the  severe  epidemic  of 
influenza  in  1847,  I  had  some  opportunities  of  examining  the  mem- 
brane in  the  early  stage  of  that  afiection,  and  I  found  it  dark-red, 
thickened,  and  even  pulpy,  like  a  highly  injected  portion  of  the  in- 
testinal mucous  membrane ;  I  also  observed  in  such  cases  an  increased 
and  apparently  acute  cerumenous  secretion  coating  the  passage. 

The  deafness  attending  typhus  fever  is  a  well-known  symptom^ 
although  its  true  pathology  has  not  been  yet  elucidated,  because  a 
sufficient  number  of  autopsies  have  not  been  made  ;  and  we  have  not 
well-authenticated  descriptions  of  the  appearances  which  the  parts 
susceptible  of  inspection  dm-ing  life  present.  In  this  country,  where 
extensive  opportunities  for  studying  typhus  exist,  the  deafness  which 
occurs  during  the  progress  of  fever  is  generally  regarded  as  a  favor- 
able symptom  ;  but  I  believe  that  that  which  arises  in  the  commence- 
ment is  not  so  favorable.  I  can  only  speak  as  to  the  results.  In  a 
few  instances  the  membrana  tympani  was  perfectly  natural,  and  the 
tympanic  cavity  free  ;  and  the  patients  presenting  such  generally  had 
a  bad  form  of  fever,  with  very  severe  head  symptoms.  Such  cases  I 
suppose  to  be  analogous  to  the  amaurosis  which  sometimes  arises  du- 
ring the  progress  of  fever,  and  often  remains  permanently,  being  a 
cerebral,  and  not  an  ocular,  disease.  But  in  the  great  majority  of  in- 
stances the  membrana  tympani  presented  evidences  of  disease,  being 
generally  thickened,  opaque,  and  collapsed ;  I  am,  therefore,  led  to 
believe  that,  in  very  many  cases,  the  deafness  occurring  during  the 
course  of  a  fever  is  the  result  of  inflammatory  action  in  the  ear  itself, 
and  not  in  the  brain.  In  this  opinion  I  am  borne  out  by  the  dissec- 
tions of  M.  Passavant,  who  says,  that  in  "  patients  cut  off  by  typhus 
fever, — and  he  has  always  found  certain  pathological  lesions  corre- 
sponding to  the  symptoms  observed  during  life, — the  petrous  portion 
of  the  temporal  bone  is  congested,  and  the  congestion  extends  to  the 
internal  parts,  except  those  of  most  solidity.  The  transparency  of 
the  tympanum  has  disappeared ;  the  membrane  is  thickened,  red,  and 


270  CHEONIC    MYRINGITIS. 

its  epithelium  peels  off  with  great  readiness.  This  injection  of  the 
membrana  tympani  extends  someway  along  the  external  auditory  canal, 
and  in  some  cases  small  spots  of  ecchymosis  are  found  between  the 
injected  vessels.  The  cavity  of  the  tympanum  contains  a  thick,  viscid 
mucus,  which  is  also  found  in  the  Eustachian  tube,  and  in  the  cells  of 
the  mastoid  process.  The  mucous  lining  of  the  middle  ear  is  con- 
gested likewise,  of  a  rose  or  bluish-red  color.  The  labyrinth  does  not 
present  any  constant  alteration,  though  some  points  of  injection  are 
occasionally  observed."^  I  have  observed  that  suppurative  otitis  is  not 
common  in  typhus,  while  it  is  the  chief  characteristic  in  the  disease 
occurring  during  the  progress  of  scarlatina  or  measles,  where  the 
membrana  tympani  is  almost  invariably  perforated,  and  a  bad  form  of 
otorrhoea  results.  I  think  it,  therefore,  more  likely  that,  when  local 
disease  is  set  up, — and  from  the  organic  changes  subsequently  ob- 
served, there  can  be  no  doubt  of  the  fact, — the  inflammation  is  seated 
in  the  fibrous  structures,  and  not  the  mucous  lining  of  the  ear.  Typhus 
occurring  in  children  is  a  cause  of  acquired  muteism,  for  which  see 
the  following  chapter,  and  also  that  on  Deaf-dumbness. 

CHRONIC   MYRINGITIS. 

Ohronic  inflammation  of  the  memhrana  tympani  is  a  very  frequent 
cause  of  deafness,  as  may  be  seen  by  referring  to  the  Table  at  page 
108 :  no  less  than  396  cases  out  of  2385,  or  one  in  every  six,  having 
presented  at  the  hospital  in  the  period  specified.  To  these  might  be 
added  the  219  cases  of  thickening  and  opacity  of  the  membrane,  but 
that,  in  a  practical  and  a  therapeutic  point  of  view,  there  is  a  mani- 
fest difference :  the  former  being  frequently  within  the  pale  of  art, 
whereas  the  latter,  if  of  long  standing,  is  generally  irremedial,  and  it 
is  more  frequently  accompanied  with  collapse.  In  chronic  myringitis 
there  is  generally  some  evidences  of  inflammatory  action  going  for- 
ward. Whatever  may  be  the  original  cause  of  the  disease,  it  is  one 
that  comes  under  our  notice  daily ;  and,  although  many  cases  pre- 
sent as  such  in  the  beginning  of  the  deafness,  the  appearances  of 
chronic  inflammation  of  the  drum  are  to  be  found  as  the  sequelae  of 
nearly  all  the  other  forms  of  inflammation,  in  the  same  way  that  we 
find  chronic  ophthalmia  so  frequently  a  sequence  of  the  various  acute 
forms  of  inflammation  of  the  eye.     In  external  otorrhoea  the  mem- 

1  Zeitschrift  fur  Rationalle  Medizin,  quoted  in  The  Medical  Times  for  April  19di,  1851. 
For  further  information  see  the  sections  on  Otitis  and  Acquired  Muteism. 


CHRONIC    MYRINGITIS.  271 

brana  tympani  is  generally  in  this  condition ;  but  there  are  two  other 
special  forms  of  chronic  inflammation  which  may  be  constantly  ob- 
served,— the  first,  a  perfectly  painless  deafness ;  the  other  attended 
by  paroxysms  of  pain,  coming  on  at  intervals,  between  which  the 
patient  is  perfectly  free  from  all  uneasiness.  The  latter  is  much 
more  common  among  females  from  twenty  to  forty,  and  is  at  times 
accompanied  by  irregularities  of  the  uterine  functions.  The  appear- 
ance of  the  membrana  tympani  is  too  peculiar  to  be  mistaken :  it  pre- 
sents a  general  thickening  and  opacity,  particularly  of  its  lower 
portion ;  besides  which  there  is  ahnost  invariably  a  number  of  spots, 
about  the  size  of  pin-heads,  of  greater  density  than  the  rest,  and  of 
a  pearly  lustre,  studded  over  the  surface  of  the  membrane.  In  many 
cases  it  presents  the  appearance  of  crumpled  parchment.  During  the 
quiescent  periods,  we  only  remark  a  few  straggling  vessels,  carrying 
red  blood,  spread  over  the  surface  of  the  membrane,  and,  for  the 
most  part,  coursing  from  above  downwards,  parallel  with  the  handle 
of  the  hammer.  Upon  any  provocation,  however,  such  as  cold,  or 
other  exciting  causes,  the  membrane  will,  in  a  few  hours,  and  often 
without  any  increase  of  pain,  become  an  uniform  dark-red  color,  pre- 
cisely like  pannus  of  the  cornea,  a  disease  of  which  it  is  the  manifest 
analogue.  The  greater  the  amount  of  thickening  .and  opacity,  the 
less  will  be  the  quantity  of  vascularity  and  redness  which  the  mem- 
brane is  capable  of  assuming,  as  we  perceive  in  cases  of  dense  opacity 
of  the  cornea,  owing,  no  doubt,  to  the  greater  quantity  of  deposit 
obstructing  the  flow  of  red  blood,  by  diminishing,  and,  perhaps,  also 
obliterating,  the  calibre  of  the  vessels.  In  such  cases  the  membrane 
is  often  insensible. 

I  have  frequently  seen  a  thin,  skim-milk-colored  scale  on  the  mem- 
brana tympani,  like  that  which  mineral  lotions,  lead,  or  alum  occa- 
sionally leave  on  the  cornea,  with  a  number  of  fine  radiating  clear 
lines  interspersed  through  it,  as  if  the  deposit  had  cracked  in  these 
places. 

Cases  of  this  kind  are  often  of  many  years'  standing,  and  many 
have,  I  am  com^nced,  been  treated  as  instances  of  "nervous  deaf- 
ness." The  following  is  no  imaginary  case,  but  one  of  constant 
occurrence. 

A  lady,  aged  between  30  and  40,  applies  for  advice.  She  is  very 
deaf,  speaks  in  a  loud,  inharmonious  voice,  and  has  sufi"ered  from 
noise  in  her  ears,  of  all  descriptions,  for  several  years.  She  usually 
prefaces  the  detail  of  her  symptoms  (which  is  generally  very  long 


272  CHRONIC    MYRINGITIS. 

and  verbose)  by  stating  that  she  does  not  think  much  can  be  done  for 
her,  for  that  she  is  laboring  under  nervous  deafness,  and  is,  therefore, 
incurable.  She  has  a  great  objection  either  to  be  questioned  or  to 
have  her  ears  examined  until  she  has  made  a  full  statement  of  her 
case  ;  and  as  she  has  had  a  great  variety  of  opinions,  and  has  used 
all  manner  of  remedies,  she  is  tediously  accurate  in  her  account. 
She  also  carries  in  her  hand  a  formidable  list  of  questions.  She 
states  that  she  has  been  deaf  from  a  very  early  period ;  that  at  first 
her  deafness  was  attributed  to  inattention,  and  endeavored  to  be 
remedied  by  the  means  thought  most  advisable  by  her  guardians  and 
governesses,  and  the  family  doctor ;  that,  her  disease  increasing,  she 
"was  brought  to  an  eminent  practitioner,  who,  after  a  few  casual  in- 
quiries, but  without  examining  her  ears,  told  her  friends  not  to  mind 
it,  for  that  she  would  certainly  "  grow  out  of  it"  as  she  grew  up,  and 
that  probably  all  her  deafness  would  disappear  about  the  period  of 
puberty ;  but  that  she  might  rub  eau  de  Cologne  on  the  jaw  occasion- 
ally !  With  the  exception  of  sea-bathing,  and  means  calculated  to 
improve  the  state  of  her  general  health,  no  other  remedies  were  tried, 
and  no  other  advice  sought  for  two  or  three  years ;  when,  not  finding 
the  hearing  improved,  but  gradually  becoming  worse,  and  the  tinnitus 
increasing  as  she  grew  up,  a  special  aurist  was  consulted,  who  stated 
the  disease  to  be  entirely  local,  and  curable  by  local  remedies  alone. 
During  the  next  few  years,  various  means  were  had  recom-se  to : 
catheterism  of  the  Eustachian  tube  was  employed  for  several  months, 
the  tympanum  constantly  washed  out,  and  various  liquids  and  gases 
injected  into  it,  but  without  effect.  Counter-irritation  was  next  em- 
ployed, with  issues  in  the  arm  and  setons  in  the  neck,  and  a  long  and 
fair  trial  given  to  their  powers.  It  was  next  proposed  to  remove  the 
tonsils,  or,  at  least,  portions  of  them.  Still  the  disease  progressed. 
Drops,  oils, — eel-oil  in  particular, — and  divers  liniments  were  tried 
in  vain. 

Broken  down  in  health,  wearied  by  the  variety  of  opinions  and  the 
multiplicity  of  applications,  another  eminent  physician  was  then  con- 
sulted, who,  having  heard  the  history  of  the  case,  advised  the  cessa- 
tion of  all  local  remedies,  and  recommended  tonics  and  antispasmodics, 
together  with  shower-baths,  change  of  air,  and  sea-bathing :  stating 
at  the  same  time  that  the  disease  was  entirely  constitutional,  and  of 
a  nervous  character.  And  certainly  by  this  time,  from  hope  deferred, 
— for  many  specious  promises  of  cure  had  been  made, — from  the  in- 
crease of  the  tinnitus,  and  from  the  effects  of  the  long  and  severe 


CHRONIC    MYEINGITIS.  273 

treatment,  tlie  patient  had  become  remarkably  nervous  and  irritable, 
brooding  over  her  malady,  and  rendered  unhappy  and  discontented 
by  being  unable  to  take  part  in  any  general  conversation. 

Some  years  now  passed  without  her  doing  anything ;  she  had  not 
become  much  worse,  but  she  certainly  had  not  improved.  Owing  to 
some  new  theory  being  started,  at  the  solicitation  of  friends  who  had 
been  reheved  of  some  curable  form  of  deafness,  or  from  the  celebrity 
of  some  particular  practitioner,  she  was  again  induced  to  seek  relief; 
and  having  arrived  at  the  metropolis,  she  took  the  round  of  the  doc- 
tors and  aurists.  Some  proposed  perforation  of  the  drum,  others 
recommended  travel ;  the  honest  prescribed  nothing ;  the  quack  prof- 
fered his  panacea,  or  offered  to  sell  his  peculiar  acoustic  instrument, 
and  backed  the  recommendation  of  its  merits  by  the  sign-manual  of 
persons  of  rank  and  position.^  The  homoeopathists,  hydropathists, 
and  mesmerists,  were  each  consulted,  and  the  merits  of  their  systems 
tested;  heavy  wet  without,  and  infinitesimal  nothings  within,  got 
every  fair  play ;  and  a  lock  of  the  lady's  hair  was  sent  to  Paris,  to  a 
celebrated  practitioner  in  electro-biology ;  the  Spas  of  England  and 
the  Badens  of  Germany  were  visited,  and  their  efficacies  tried;  elec- 
tricity, galvanism,  and  electro-magnetism,  were  also  had  recourse  to, 
but  all  in  vain.  The  opinions  of  those  whom  she  had  consulted  were 
as  various  as  the  remedies  they  employed :  but  the  greater  number 
believed  it  to  be  a  constitutional  or  nervous  affection.  Latterly  she 
had  been  content  to  look  out  for  "cures"  among  the  newspaper  ad- 
vertisements, and  of  these  she  possessed  a  large  number  in  her  port- 
folio. 

Of  several  such  cases,  scarcely  differing  in  a  shade,  I  possess  the 
notes.  In  these  the  following  may  be  gleaned  upon  a  careful  exami- 
nation. The  membrana  tympani  is  thickened,  opaque,  slightly  vascu- 
lar, and  sometimes  much  collapsed  or  drawn  inward  towards  the 
inner  wall  of  the  tympanum,  so  that  the  handle  of  the  hammer  forms 
a  manifest  projection :  it  has  also  lost  its  polish  and  become  of  a  dull 
pearl-color.  On  questioning  the  patient  closely,  it  is  acknowledged 
that  attacks  of  earache  were  suffered  several  years  previously,  par- 
ticularly in  winter,  and  that  such  attacks  were  often  preceded  or 
accompanied  by  stuffing  in  the  nose,  and  symptoms  of  catarrh,  and 

'  In  a  window  in  the  Strand,  not  far  from  Soirierset  House,  London,  may  be  seen, 
framed  and  glazed,  a  certificate  from  one  of  the  Chief  Justices  of  England,  lauding  and 
recommending,  "  to  all  whom  it  may  concern,"  a  particular  form  of  ear  trumpet ! 

18 


274  CHRONIC    MYRINGITIS. 

were  generally  induced  by  cold,  to  avoid  which  the  head  was  usually 
kept  warmly  muffled  during  such  seasons. 

In  such  a  case  our  art  at  present  does  not  offer  much  hope.  The 
whole  train  of  symptoms  are  evidently  the  result  of  slow  chronic  in- 
flammation, affecting,  in  all  probability,  the  lining  of  the  cavity,  as 
well  as  the  membrane  of  the  drum,  like  repeated  attacks  of  choroido- 
iritis  in  the  eye.  The  only  means  which  can  with  safety  be  recom- 
mended at  this  period  is  the  application  of  a  solution  of  lunar  caustic, 
applied  with  a  camel's  hair  brush,  every  third  or  fourth  day,  upon 
the  surface  of  the  opaque  membrane,  while  it  is  fully  exposed  to  view, 
and  should  there  be  much  vascularity  present,  the  application  of  a 
few  leeches  as  far  as  possible  round  the  meatus,  at  least  twice  a  week. 
In  a  few  cases  the  arnica  will  assist  to  remove  the  tinnitus ;  but  it  is 
not  so  efficacious  in  this  as  in  more  recent  forms  of  the  affection. 

In  the  cases  of  periodic  pain,  with  a  higher  degree  and  more  gene- 
rally diffused  vascularity,  the  application  of  leeches,  applied  every 
second  or  third  day,  will  be  found  most  efficacious ;  at  the  same  time 
that  the  patient  should  be  brought  under  the  gentle  influence  of  mer- 
cury, and  kept  so  for  at  least  a  month.  Under  such  treatment,  if 
the  case  is  not  of  too  long  standing,  the  hearing  will  often  be  im- 
proved, and  the  symptoms  of  pain  and  tinnitus  removed.  The  mem- 
brane will  clear  somewhat,  but  in  most  cases  the  spots  of  opacity 
remain  indelible.  In  applying  the  solution  of  nitrate  of  silver  with  a 
fine  brush,  or  a  bit  of  cotton-wool  on  the  end  of  a  probe,  some  caution 
and  dexterity  are  required,  as  the  membrane  may  present  a  small 
perforation  the  next  day  if  it  has  been  rubbed  too  hard ;  and  although 
I  have  always  seen  such  perforations  heal  readily,  it  is  an  accident 
which  should  be  avoided.  By  this  application  dark  scales  peel  off 
the  surface  of  the  membrane,  and  leave  it  thinner  and  more  trans- 
parent than  before ;  but  the  moment  it  becomes  inflamed  we  must 
desist.  I  knew  two  instances  in  which  the  tinnitus  was  always' re- 
lieved for  several  hours  or  even  a  day  after  simply  rubbing  the  sur- 
face of  the  membrana  tympani  with  a  bit  of  moist  cotton. 

There  is  a  form  of  deafness  with  which  I  have  been  long  familiar, 
which  may  be  the  result  of  some  form  of  inflammation.  In  such 
cases,  upon  bringing  the  external  membrane  of  the  drum  into  view, 
we  do  not  observe  any  general  thickening  or  opacity  of  it,  or  any 
apparent  alteration  of  its  texture,  but  a  crescent-shaped  opacity, 
about  a  line  broad  and  three  lines  long,  with  a  tolerably  defined  edge, 
and  rather  rough  upon  its  surface,  occupies  the  lower  and  usually  the 
back  portion  of  the  membrane.     It  is  generally  more  insensible  than 


MOKBID     DEPOSITS    IN    THE    MEMBRANA    TYMPANI.      275 

the  rest  of  tlie  membrane,  and  differs  from  the  ordinary  opacity,  in 
the  surrounding  structure  being  apparently  free  from  disease,  in  its 
almost  invariable  seat,  its  well  defined  edge,  and  in  its  having  a  por- 
tion of  unafiected  membrane  between  it  and  the  bony  attachment  of 
the  membrana  tympani.  By  a  very  slow  and  gradual  process  this 
disease  spreads  over  the  greater  portion  of  the  membrane,  and  pro- 
duces permanent  deafness.     I  am  not  aware  of  any  remedy  for  it. 

In  some  instances  I  have  observed  a  manifest  granular  state  of  the 
membrane,  not  unlike  the  surface  of  a  half-ripe  raspberry,  the  inter- 
vening portions  between  the  reddish  elevations  being  thickened  and 
opaque ;  it  is  unattended  by  discharge.  In  these  cases  I  have  pro- 
cm'ed  an  uniform  thinning  and  clearing  of  the  membrane,  by  the  oc- 
casional application  of  a  fine  point  of  nitrate  of  silver ;  but  this 
requires  very  great  care,  and  should  be  persevered  in  for  a  great 
length  of  time,  at  least  two  months ;  it  should,  if  possible,  be  applied 
so  lightly  as  not  to  induce  a  discharge.  Many  of  those  cases  are  the 
result  of  long-continued  otorrhoea,  but  which,  having  healed,  has  left 
the  membrane  in  this  condition. 

Many  females  have  become  deaf  immediately  after  parturition. 
In  such  cases  I  have  generally  observed  a  speckled  opacity  of  the 
membrane. 

No.  9  in  the  Registry  is  a  case  of  thickening  and  opacity  of  the 
membrana  tympani. 

A.  H.,  a  female,  aged  30 :  complains  of  deafness,  tinnitus  aurium, 
and  constant  pain  in  her  right  ear,  and  partially  in  the  left.  General 
health  impaired,  she  says,  on  account  of  her  aural  affection;  the 
almost  incessant  hammering  noise,  and  the  pain — aggravated  when- 
ever she  gets  cold — rendering  her  very  miserable  and  nervous.  The 
membrana  tympani  upon  the  right  side  is  of  a  pearl-color,  and  evi- 
dently thickened  by  some  interstitial  deposit ;  it  has  lost  its  polish, 
but  retains  its  natural  position,  and  the  patient  can  press  it  outward 
by  inflating  the  drum.  Posteriorly,  there  is  a  well-defined  streak  of 
dense  white  opacity  proceeding  downwards  and  outwards  from  the 
point  of  the  malleus.  Hearing  distance  three  inches.  Left  side 
nearly  natural ;  hearing  distance  twelve  inches.  Scarcely  ever  feels 
any  pain  unless  when  much  exposed  to  cold. 

MORBID    DEPOSITS   IN   THE   MEMBRANA   TYMPANI. 

Thickening  and  opacity  of  the  membrana  tympani,  with  or  without 
flattening,  collapse,  or  drawing  inwards  towards  the  cavity  of  the 


276      MOEBID    DEPOSITS    IN    THE    MEMBRANA     TYMPANI. 

tympanum,  is  the  most  frequent  apparent  result  of  eacli  and  all  of 
the  foregoing  varieties  of  inflammation  in  that  structure.  If  we 
examine  into  the  sequelae  of  ophthalmic  inflammation,  we  find  that 
opacity  either  of  the  cornea  or  lens  is,  in  a  great  majority  of  those 
instances  in  which  the  organ  has  not  been  totally  destroyed,  the  chief 
cause  of  loss  of  vision.  Lymph  eff"used  upon  either  side  of  the  mem- 
brana  tympani  or  between  its  laminae  is  the  manifest  consequence  of 
most  inflammations,  in  addition  to  which  the  external  cuticular  layer 
may  be  thickened  from  pressure,  as  already  explained  at  page  189, 
or  by  extension  of  cutaneous  diseases,  as  shown  at  page  198 ;  and 
within,  the  increased  vascularity  and  hypertrophy  of  the  mucous 
lining  of  the  tympanic  cavity  over  the  posterior  surface  of  the  mem- 
brana  tympani  naturally  gives  rise  to  permanent  thickening  of  this 
structure.  An  examination  of  the  Registry  of  200  cases  in  the  pre- 
vious part  of  this  work,  and  the  analysis  of  that  Registry,  at  page 
141,  will  explain  the  various  conditions  of  the  membrane  to  which  I 
have  so  frequently  alluded.  It  is  possible  that  in  those  cases  where 
we  observe  clear,  pocket-like  projections  in  the  surrounding  opaque 
membrane,  that  either  from  rupture,  ulcer,  or  an  outspreading  of  the 
fibres  of  the  true  central  laminse,  that  there  is  a  partial  deficiency  of 
the  membrane  at  these  spots;  but  we  require  minute  pathological 
investigation  to  determine  which  particular  structure  is  deficient.  It 
is,  however,  very  probable  that  these  projections  are  formed  by  the 
mucous  membrane  bulging  through,  and  the  dermoid  layer  being 
pressed  outwards,  like  what  takes  place  in  a  sacculated  bladder,  occa- 
sionally in  the  iris,  and  often  in  the  cornea. 

Atheromatous  or  calcareous  deposits  form  between  the  laminse 
of  the  membrana  tympani,  and  generally  occur  in  middle-aged 
females.  The  deposit  is  usually  seated  in  the  anterior  vibrating 
portion,  is  of  a  yellowish  color,  and  has  a  sharp,  well-defined,  but 
irregular  edge,  totally  different  from  that  of  a  lymphy  exudation, 
which  generally  shades  off"  into  the  surrounding  membrane.  If 
scratched  with  a  cataract  needle,  it  will  be  found  gritty,  but  what  its 
exact  composition  is  I  cannot  tell.  I  believe  I  was  the  first  to  notice 
this  peculiar  appearance,  ten  years  ago,  in  my  essay  upon  Otorrhoea, 
where  I  then  stated,  at  page  38,  "  I  have  in  three  instances  seen 
earthy  deposits  between  the  layers  of  the  membrane  like  those  which 
are  found  in  the  heart  and  arteries  and  cornea ;  they  are  regular  in 
shape,  occupied  about  one-half  of  the  tense  portion  of  the  membrane, 
and  afforded  a  gritty  feel  when  touched  with  a  sharp  instrument.  In 
each  case,  severe  deafness  existed  in  that  ear.     In  one  of  these  cases, 


MOEBID    DEPOSITS     IN    THE    MEMBRANA    TYMPANI.      277 

that  of  Lady  B.,  I  pointed  out  this  peculiar  morbid  deposit  to  Sir  H. 
Marsh,  about  eight  months  ago"  (1843).  Four  such  cases  are  no- 
ticed in  the  Registry  (see  page  142),  and  I  have  also  seen  several 
others  in  private  practice.  Sensibility  remains  in  these.  I  believe 
the  disease  to  be  incurable. 

Thickening  and  opacity  of  the  membrane  is  as  difficult  of  cure  as 
the  same  appearance  in  the  cornea.  Much  must  depend  upon  the 
age  of  the  patient,  who  may  outgrow  it ;  upon  the  state  of  the  general 
health,  from  the  removal  of  the  oj)acity,  being  a  process  of  absorp- 
tion ;  and  also  upon  the  length  of  time  which  has  elapsed  since  the 
original  inflammation  existed.  The  diagnosis  should  always  be 
guarded :  if  redness  and  vascularity  still  linger  about  the  membrana 
tympani  and  external  meatus,  we  may  entertain  a  hope  of  improving 
the  patient's  condition  by  the  means  pointed  out  for  treating  chronic 
inflammation  in  the  foregoing  section,  and  the  employment  of  such 
constitutional  and  dietetic  measures  as  serve  to  correct  or  alter  the 
exciting  cause.  But  if  the  patient  has  passed  thirty  years  of  age  ;  if 
all  vascularity  has  been  removed ;  if  the  meatus  is  dry,  scaly,  and 
totally  devoid  of  cerumen,  and  that  the  membrana  tympani  presents 
upon  its  external  surface  a  uniform  sheet  of  pearlaceous  whiteness, 
with  perhaps  one  or  two  superficial  red  vessels  corn-sing  along  the 
malleus,  treatment  does  not  hold  out  a  hopeful  chance  of  success. 
We  see  enough  of  manifest  disease  to  account  for  the  deafness,  but 
we  cannot  tell  in  what  condition  the  membrane  lining  the  tympanic 
cavity  may  be ;  what  amount  of  opacity  and  thickening  may  have 
taken  place  in  the  membrane  of  the  fenestra  rotunda ;  whether  an- 
chylosis of  the  stapes  to  the  fenestra  ovalis  exists ;  or  whether  bands 
of  adhesion  have  formed  between  the  membrana  tympani  or  the  ossi- 
culse  and  neighboring  parts.  Even  supposing  that  none  of  these 
pathological  changes  have  happened,  and  that  the  disease  simply  con- 
sists in  an  opacity  of  the  membrana  tympani,  and  that  the  patient  is 
in  good  health,  and  absorption  going  forward,  a  year  and  more  must 
occur  before  we  can  expect  the  membrane  to  clear,  either  in  whole  or 
in  part,  and  few  persons  will  be  found  with  sufficient  confidence  and 
patience  to  carry  out  the  prescribed  treatment ;  yet  I  have  some- 
times been  astonished  at  the  favorable  turn  which  some  of  the  most 
unpromising  cases  have  taken,  in  the  instance  of  persons  who,  like 
the  woman  in  Scripture,  prevailed  through  their  importunity,  even 
after  I  had  given  a  most  unfavorable  prognosis. 

The  treatment,  like  that  of  chronic  inflammation,  consists  in  paint- 


278  COLLAPSE     OF    THE     MEMBRANA    TYMPANI. 

ing  over  the  surface  of  the  membrane  with  a  solution  of  nitrate  of 
silver,  of  from  ten  to  twenty  grains  to  the  ounce,  about  twice  a  week. 
A  camel's  hair  pencil  is  not  so  good  a  means  of  applying  it  as  a  bit 
of  cotton-wool  twisted  round  the  end  of  a  probe,  as  it  should  not 
merely  be  applied,  but  rubbed  over  the  membrane,  which  in  such 
cases  is  almost  insensible,  and  after  a  few  applications  will  become 
blackened  in  patches,  showing  the  usual  effect  of  lunar  caustic  on 
dermoid  structures.  We  must  then  desist  until  these  dark  scales 
peel  off,  and  when  they  do,  we  should  continue  the  application. 
Should,  hoAvever,  the  membrane  become  vascular  or  inflamed  during 
the  process,  the  use  of  the  caustic  must  be  omitted  until  the  parts 
become  quiescent.  The  patient,  if  intelligent  and  careful,  may  be 
taught  to  apply  the  caustic,  but  the  parts  should  be  inspected  at  least 
once  a  fortnight.  Under  this  plan  of  treatment  I  have  succeeded  in 
thinning  the  membrane  and  restoring  hearing  in  most  unpromising 
cases,  whereas  in  others  I  have  utterly  failed.  I  have  tried  iodine 
and  other  substances,  but  have  not  succeeded  with  any  so  well  as  the 
nitrate  t)f  silver.  Counter-irritation  should  at  the  same  time  be  kept 
up  over  the  mastoid  process. 

COLLAPSE    OF   THE    MEMBRANA   TYMPANI. 

Collapse,  or  falling  inwards,  of  the  membrani  tympani,  toward  the 
middle  ear,  is  a  very  constant  appearance  observed  in  making  aural 
examinations,  as  already  remarked  in  the  Analysis  of  the  Registry 
at  page  143,  where  this  peculiar  affection  is  described.  I  have  re- 
marked two  forms  of  this  peculiarity.  In  one  the  membrane  is  thick- 
ened, opaque,  and  exhibits  all  the  evidences  of  previous  inflammation ; 
in  the  other,  its  texture  is  unaltered,  it  has  merely  become  pressed 
inward  towards  the  cavitas  tympani,  leaving  the  tubercle  and  handle 
of  the  malleus  projecting  outwards  in  strong  relief.  The  former  is 
always  accompanied  by  severe  deafness ;  with  the  latter  form  need 
only  be  associated  tinnitus,  although  deafness  often  accompanies  it. 
Cleland  was  aware  of  this  peculiar  condition  of  the  membrana  tympani 
more  than  one  hundred  years  ago,  as  I  have  shown  at  page  29  of 
this  work,  to  which  passage  I  would  here  refer  the  reader.  Several 
old  authors  have  written  upon  a  disease  which  they  call  relaxation  of 
the  membrana  tympani, — -Willis,  Joseph  Frank,  and  others,  supposing 
that,  when  it  was  relaxed,  it  fell  imvards,  while  Beck  conceived  that 
it  pressed  out  towards  the  external  auditory  passage,  which,  I  believe, 


COLLAPSE    OF    THE    MEMBRANA    TYMPANI.  279 

only  occurs  from  accumulations  in  the  tympanum.  Were  we  to  rely 
upon  authorities  and  not  upon  observations  and  facts,  we  might  still 
look  upon  the  question  as  undecided ;  but  that  the  membrane  is,  from 
some  cause  or  other,  frequently  rendered  more  concave  than  natural 
and  pressed  inwards  towards  the  tympanum,  does  not  admit  of  a 
doubt.  Kramer,  in  his  criticism  of  Willis,  adduces  as  insupportable 
the  assertion  of  some  forms  of  deafness,  being  improved  by  loud 
noises  occurring  in  the  vicinity, — as,  for  instance,  while  a  drum  was 
beaten  in  a  room,  and  "  that  an  individual,  whose  hearing  was  defec- 
tive, heard  everything  during  the  ringing  of  a  peal  of  bells."  Yet, 
it  is  a  well-established  fact,  that  certain  deaf  individuals  will  be  able 
to  hear  the  human  voice  in  its  ordinary  tones,  and  to  enter  into  con- 
versation while  travelling  in  a  carriage,  walking  in  a  street  through 
which  vehicles  are  passing,  or  under  any  circumstance  in  which  the 
air  is  agitated  by  noises  much  louder  than  those  in  which  the  con- 
versation they  are  listening  to  are  addressed.  Thus,  I  knew  an 
instance  of  a  miller  who  could  hear  perfectly  well  ordinary  conversa- 
tion while  standing  within  the  working  mill,  but  so  soon  as  the  mill 
ceased,  or  that  he  removed  into  another  locahty,  he  could  only  hear 
when  spoken  to  in  a  much  louder  tone  of  voice.  This  peculiar  symp- 
tom, a  satisfactory  explanation  for  which  has  not  yet  been  given,  has 
generally  been  enumerated  as  one  of  the  characteristics  of  true  ner- 
vous deafness.  Thus,  Kramer  himself,  when  describing  his  "  erethitic 
form  of  nervous  deafness,"  says,  notwithstanding  his  previous  criticism 
of  AYillis,  that,  "  if  the  patient  sit  in  a  cart  which  is  rattling  quickly 
over  a  stone  pavement,  or  presses  his  forehead  against  the  frame  of  a 
window  whilst  a  wagon  is  rattling  past,  so  that  the  whole  house  is 
shaken  by  it ;  or  if  a  peal  of  bells  be  ringing  near  the  patient,  or  a 
drum  be  beaten,  the  auditory  nerve  becomes  so  excited  by  those  deep- 
toned  uniform  noises  that,  whilst  they  continue,  the  patient  often 
hears  the  human  voice  better  than  a  sound  person  whose  ear  is  stunned 
by  the  noise."  The  facts  are  certainly  as  thus  stated,  but  the  infe- 
rence does  not  follow.  We  have  no  authority  for  believing,  neither 
are  there  any  known  physiological  circumstances  to  warrant  the 
assertion,  that  the  auditory  nerve  becomes  thus  excited ;  or,  if  excited 
by  grave  tones,  that  it  is  at  that  moment  more  capable  of  appreciating 
sharp  or  acute  tones.  This  peculiar  phenomenon  has  always  appeared 
to  me  more  explicable  by  a  consideration  of  the  state  of  the  membrana 
tympani,  and  it  is  remarkable  that  it  does  not  occur  in  cases  where 
that  structure  has  been  in  whole  or  in  part  removed.     Cleland,  as  I 


280  COLLAPSE    OF    THE    MEMBRANA    TYMPANT. 

have  already  remarked,  believed  that  the  altered  position  of  the 
memhrana  tympani  was  caused  by  "  a  violent  clap  of  thunder,  noise 
of  cannon,  or  the  like."  I  do  not  remember  having  met  with  an 
instance  arising  from  the  former  cause ;  but  it  is  not  improbable,  that 
some  of  the  cases  of  deafness  which  commonly  occur  among  the  artil- 
lery may  be  owing  to  a  collapse  of  the  membrana  tympani. 

The  cause  of  collapse  some  writers  have  endeavored  to  explain,  by 
supposing  that  the  tensor  tympani  muscle  had  snapped,  or  that  the 
ossicula  and  mechanical  apparatus  of  the  middle  ear  had  become 
deranged ;  but,  from  the  fact  that,  in  all  cases  of  collapse,  the  handle 
of  the  malleus  is  not  drawn  inwards  along  with  the  membrane  on 
each  side  of  it,  I  am  not  inclined  to  entertain  that  opinion.  I  believe 
the  collapse  may,  in  most  instances,  be  attributable  to  one  or  other  of 
two  causes, — partial  or  complete  closure  of  the  Eustachian  tube,  by 
which  means  the  pressure  of  the  external  atmosphere  must  of  necessity 
drive  the  membrane  inwards ;  and  inflammation  of  the  cavity  of  the 
tympanum,  when  adhesive  bands  have  formed  between  the  internal 
surface  "of  the  membrane  and  the  neighboring  parts,  which,  as  shown 
by  the  dissections  of  Mr.  Toynbee  at  page  117,  appeared  in  as  many 
as  179  instances  out  of  915  examinations. 

This  is  a  cause  of  deafness  most  difficult  to  treat ;  but,  unless  some 
other  disease  coexist  with  it,  we  may  generally  assure  the  patient 
that  the  deafness  will  not  increase.  When  once  the  membrane  has 
been  pressed  for  any  length  of  time  inwards,  it  is  very  difficult  to 
restore  its  position  permanently.  Many  persons  inflate  the  drum,  by 
holding  the  nose  and  making  a  forced  expiration  whenever  they  wish 
to  hear  what  is  said.  In  others  we  can  temporarily  restore  the  natu- 
ral position  by  Eustachian  catheterism ;  but  in  both  the  membrane 
returns  to  its  former  condition  in  a  short  time.  I  have  tried  the 
effect  of  exhausting  the  air  in  the  external  meatus  by  means  of  a 
syringe  accurately  adjusted  to  the  outer  aperture ;  but  I  have  not 
effected  any  good  thereby.  On  the  contrary,  I  think  the  congestion 
produced  by  the  exhaustion  is  rather  detrimental  to  the  organ.  I 
have  frequently  afforded  temporary  relief  by  dropping  with  a  glass 
tube  a  little  nitrous  ether  into  the  meatus,  and  immediately  stopping 
the  external  aperture  either  with  the  finger  or  by  pressing  the  tragus 
over  it.  Some  slight  pain  is  instantaneously  felt,  followed  by  a  boil- 
ing sensation,  then  a  glow  of  heat,  and  a  feeling,  to  use  the  patient's 
expression,  as  "  if  the  drum  of  the  ear  was  sucked  out."     It  is  diffi- 


COLLAPSE    OF    THE    MEMBRANA    TYMPANI.  281 

cult  to  understand  how  this  remedy  acts,  and  assists  to  restore  the 
membrane  to  its  normal  position. 

The  following  case,  No.  15  in  the  Registry,  showing  thickening 
and  collapse  of  the  membrana  tympani  on  both  sides,  is  highly  cha- 
racteristic of  the  affections  described  in  the  three  foregoing  sections. 

M.  K.,  a  married  female,  aged  46,  has  suffered  from  deafness 
accompanied  by  noise  in  her  ears,  occasional  headaches,  and  general 
nervousness,  for  the  last  ten  years.  Cannot  hear  the  ticking  of  the 
watch,  though  pressed  against  the  ears,  on  either  side.  Her  disease 
crept  on  gradually ;  is  made  worse  on  catching  cold.  She  has  not 
experienced  pain  in  the  ears,  and  has  no  hereditary  tendency  to  deaf- 
ness. The  tongue  is  clean ;  throat  normal ;  pulse  natural ;  digestive 
functions  healthy ;  the  voice,  however,  is  harsh,  husky,  and  inharmo- 
nious, showing  that  she  has  been  deaf  a  long  time. 

What  have  we  learned  from  the  subjective  symptoms  just  detailed 
of  the  actual  cause,  proximate  or  remote,  of  the  deafness  in  this  case  ? 
Absolutely  nothing.  Its  early  history  is  obscure,  and  the  symptoms 
described  are  common  to  many  affections  of  the  ear.  By  her  ordinary 
medical  attendant,  if  she  was  in  the  rank  of  life  to  have  one,  her 
disease  would  be  set  down  as  a  case  of  "nervous  deafness,"  because 
it  has  been  of  such  long  standing,  has  resisted  or  is  now  unamenable 
to  treatment,  and  because  this  poor  woman  has,  from  her  loss  of 
hearing,  and  the  noise  in  her  ears,  become  "so  nervous."  Her 
treatment,  she  says,  has  consisted  in  being  syringed  by  a  doctor,  who, 
finding  the  remedy  ineffectual,  then  recommended  her  "not  to  be 
quacking,  lest  she  might  lose  the  little  hearing  she  had;"  in  pouring 
"drops,"  which  she  saw  advertised  in  a  newspaper,  into  her  ears 
every  night  for  three  weeks;  in  using  "brandy  and  salt,"  which  a 
charitable  lady  recommended  to  her  as  an  infallible  remedy  when  that 
nostrum  was  in  vogue;  in  inserting  a  "piece  of  rusty  bacon"  into 
her  ears  at  the  suggestion  of  an  "old  woman;"  in  applying  glyce- 
rine, because  she  heard  it  could  do  no  harm ;  and,  lastly,  in  having 
tobacco-smoke  blown  into  her  ears  by  a  "travelling  aurist,"  which 
caused  her  to  faint,  and  rendered  her  weak  and  debilitated  for  several 
days  after.  Since  then,  having'lost  confidence  in  treatment,  she  has 
not  ventured  to  seek  relief. 

Let  us  now  see  what  is  the  state  of  the  affected  organ.  The 
appearances  are  nearly  the  same  on  both  sides ;  the  meatus  is  rather 
smaller  than  natural,  dry,  vascular,  and  totally  devoid  of  cerumen ; 
the  membrana  tympani  is  thickened,  white,  and  greatly  collapsed,  so 


282  COLLAPSE    OP    THE    MEMBEANA    TYMPANI. 

that  the  tubercle  and  handle  of  the  malleus,  to  which  it  is  attached, 
stand  out  much  more  prominently  than  they  ought.  Owing  to  the 
irritation  produced  by  the  insertion  of  the  speculum,  several  red 
vessels  have  begun  to  appear  upon  the  tympanal  membrane,  particu- 
larly along  the  site  of  the  malleus.  These  are  not  the  appearances 
of  present  inflammation,  but  are  the  result  of  the  enlargement  of  the 
vessels,  caused  by  long-continued  previous  inflammatory  action ;  and 
they  are  now  rendered  apparent  by  the  slightest  irritation.  We 
constantly  observe  the  same  phenomenon  in  an  eye  which  has  recently 
suffered  from  internal  ophthalmia.  The  conjunctiva  and  sclerotica 
may  be,  to  all  appearance,  natural ;  but  upon  rubbing  the  globe  with 
the  lid,  or  subjecting  it  to  any  other  exciting  process,  we  reproduce 
the  well-marked  pinkish  zone  round  the  cornea  which  characterizes 
inflammations  of  the  internal  tunics.  This  patient  has  not  suffered 
pain  in  the  ears,  and  the  absence  of  this  symptom  is  often  brought  up 
by  medical  men  in  proof  of  the  non-inflammatory  nature  of  the 
disease ;  but  we  all  know  noAV,  that  subacute  inflammation  may  exist 
in  other- organs  of  the  body, — in  the  lungs,  the  eye,  the  liver,  and  the 
mucous  and  serous  membranes, — without  the  patient  being  sensible  of 
pain.  She  cannot  fully  inflate  the  drum,  but  she  can  raise  up  the 
tympanal  membrane  a  little — a  proof  that  the  Eustachian  tube  is 
free — and  also  render  it  more  vascular.  The  inflammatory  process 
has,  in  all  likelihood,  not  been  confined  to  the  external  membrane  of 
the  tympanum,  but  has  spread  over  the  mucous  lining  of  that  cavity ; 
and  it  is  more  than  probable  that  bands  of  adhesion  exist  in  the  middle 
ear,  similar  to  those  which  dissection  occasionally  shows  us  between 
the  pleura  pulmonalis  and  pleura  costalis,  between  the  various  reflec- 
tions of  the  peritoneum,  or  between  the  back  or  pupillary  edge  of  the 
iris  and  the  anterior  capsule  of  the  lens. 

As  the  amount  of  apparent  disease,  and  the  morbid  changes  which 
are  manifest  in  this  case,  are  insufficient  to  account  for  the  great  loss 
of  hearing,  we  must  attribute  the  defect  to  an  extension  of  the 
inflammation  from  the  middle  into  the  internal  ear,  affecting  the  vesti- 
bule and  labyrinth,  and  possibly  thickening  or  rendering  invibratile 
the  membrane  of  the  fenestra  rotunda.  Analogy  with  the  pathology 
of  the  eye  here  again  assists  us.  In  many  instances  of  internal 
ophthalmia  do  we  not  observe  similar  phenomena,  where  the  amount 
of  mischief  done  to  the  sensitive  apparatus  is  not  commensurate  with 
the  evidence  of  disease  in  the  external  mechanism,  and  the  more  deli- 
cate the  organization,  the  less  is  the  morbid  product  apparent  ?     This 


PERFOKATIO^T    OF    THE     MEMBRANA    TTMPANI.        283 

woman's  chief  complaint  is  of  the  noise  in  her  ears,  which  is  so  dis- 
tressing that  it  disturbs  her  sleep,  affects  her  mind,  and  prevents  her 
following,  with  any  degree  of  energy  or  interest,  the  ordinary  occu- 
pations of  life. 

Treatment  holds  out  but  little  hope  of  amendment  in  such  a  case 
as  this,  which  is  one  of  very  common  occurrence  indeed,  in  this 
country.  The  strong  solution  of  nitrate  of  silver  applied  upon  the 
thickened  membrane  may  produce  some  alleviation,  particularly  of 
the  tinnitus ;  but,  from  the  amount  of  collapse,  it  did  not  present  a 
sufficient  warrant  to  attempt  relief  by  perforation.  It  is  manifest 
that,  when  the  membrana  tympani  is  thus  collapsed  and  bound  down, 
it  ceases  to  vibrate  on  the  impingement  of  sound. 

ARTIFICIAL    PERFORATION    OF    THE    MEMBRANA   TYMPANI. 

This  seems  the  proper  place  to  consider  the  propriety  of  perforat- 
ing the  membrana  tympani,  the  cases  to  which  it  is  applicable,  and 
the  best  mode  of  performing  it.  Closure  of  the  Eustachian  tube, 
accumulation  of  extraneous  matter  within  the  tympanum,  and  the 
thickened  condition  of  the  membrana  tympani  previously  described, 
are  the  circumstances  which  writers  seem  to  think  demand  it.  I  do 
not  believe  it  to  be  either  required  or  applicable  in  the  first  class  of 
cases ;  but  that  subject  will  be  considered  more  at  length  in  the  chapter 
upon  Diseases  of  the  Eustachian  tube.  When  we  are  convinced  that 
the  cavity  of  the  tympanum  is  filled  with  uncoagulated  blood,  and  that 
it  cannot  find  exit  through  the  Eustachian  tube,  an  aperture  may  be 
made  in  the  membrane  to  give  it  vent ;  but  such  an  aperture,  being 
intended  to  close  after  it  has  performed  its  ofiice,  is  widely  different 
from  perforation  made  by  cutting  out  a  portion  of  that  structure  for 
the  purpose  of  assisting  hearing.  To  relate  the  whole  history  of  the 
operation  for  perforation,  the  cures  said  to  have  been  achieved  by  it, 
the  various  ingenious  instruments  invented  for  performing  it,  and  the 
number  of  essays  wi'itten  by  distinguished  men  upon  the  subject, 
would  occupy  more  space  than  it  is  worth  in  a  practical  work  of  this 
description — ^more  particularly  as  the  operation  has  fallen  into  disuse 
of  late,  Eustachian  catheterism  having  in  part  superseded  it,  and 
several  of  the  so-called  cures  not  having  stood  the  test  of  time  and 
close  investigation,  so  that  no  well-authenticated  recoveries  by  the 
operation  have  been  related  for  several  years  past. 

To  Su'  Astley  Cooper  has  been  awarded  the  merit  of  first  intro- 


284       PERFORATION    OF    THE    MEMBRANA    TYMPAWI. 

ducing  the  operation :  he  performed  it  -with  a  small  trochar,  but  the 
aperture  made  therewith  was  soon  found  to  close.  There  has  not 
been,  perhaps,  in  the  whole  history  of  medicine  during  the  present 
century  a  discovery  to  which  so  much  praise  was  at  the  time  awarded, 
that  subsequent  investigation  and  experience  have,  to  say  the  least  of 
it,  so  much  disparaged.  In  the  first  place,  the  celebrated  author  was 
not,  as  I  have  shown  at  page  30,  the  original  inventor  of  the  opera- 
tion ;  although  I  feel  convinced  he  was  unacquainted  with  Degravers's 
cases,  but  the  fault  lay  with  those  who,  perhaps,  too  rapidly,  and 
without  sufficient  examination,  awarded  honors  well  due  to  the  man, 
but  undeserving  the  subject.  Itard  tried  the  operation  in  a  great 
number  of  instances,  but  without  any  determined  beneficial  result. 
Kramer,  whose  work  contains  a  very  just  review  of  the  operation  and 
the  authors  who  have  supported  it,  states,  "that  the  thickening  of 
this  membrane,  unaccompanied  by  any  other  disease  of  the  ear,  inva- 
riably affords  the  only  true  indication  for  its  perforation."  Himly 
invented  an  instrument  which  obviated  the  closure  made  by  the  sim- 
ple puncture  of  the  trochar,  or  any  other  piercing  instrument,  and 
this  has  been  further  modified  by  Fabrizzi  and  others.  The  very  in- 
genious instrument  of  the  latter  consists  in  a  fine,  round  stem,  four 
inches  long,  fashioned  at  the  end  into  a  small  corkscrew  point,  and 
enclosed  within  a  canula  working  next  the  handle  on  a  nut,  and  fur- 
nished at  the  point  with  a  sharp  steel  cutting  edge.  When  the  punch 
or  canula  is  screwed  home,  the  twisted  end  of  the  stilette  projects 
about  the  eighth  of  an  inch  beyond  its  extremity.  With  the  end  of 
the  handle  resting  in  the  centre  of  the  palm,  and  grasped  by  the 
middle,  ring,  and  little  fingers,  the  instrument  is  passed  down  to  the 
membrana  tympani,  and  then  its  spiral  point  is  inserted  into  either 
the  anterior  vibrating  portion  or  the  posterior  clear  space,  and  given 
one  or  two  turns,  so  as  to  fix  it  into  the  membrane,  which,  being  thus 
held  fast,  the  bur  or  nut  in  the  end  of  the  canula  is  twisted  between 
the  thumb  and  index  finger  outwards,  or  from  the  operator,  until  by 
this  circular  motion  the  cutting  end  of  the  punch,  revolving  against 
the  portion  of  the  membrane  held  by  the  end  of  the  stilette,  cuts  it 
out  and  removes  it  entire,  leaving  a  round  aperture  the  size  of  itself. 
This  operation  can  only  be  safely  performed  with  the  aid  of  the  specu- 
lum, and  by  having  a  stream  of  clear  sunlight  transmitted  to  the 
membrane.  The  head  must  be  held  against  some  resisting  substance, 
and  the  patient  should,  if  the  Eustachian  tube  be  free,  be  directed  to 
inflate  the  tympanum  at  the  moment.  Still,  the  greatest  delicacy  of 
manipulation,  and  a  fine,  educated  touch,  are  requisite.     The  objection 


PERFOKATION    OF    THE    MEMBRANA    TYMPANI.        285 

to  tills  and  any  similar  instrument  is  that,  from  its  size  and  the  posi- 
tion of  the  handle,  the  view  of  the  parts  under  operation  is  obscured. 
To  remedy  this  defect  Mr.  Yearsley  had  an  instrument  made  with  a 
bend  near  the  handle, — upon  the  principle  of  the  curve  which,  some 
years  ago,  I  recommended  in  the  formation  of  all  instruments  em- 
ployed upon  the  memhrana  tympani,  and  described  at  page  67. 

With  respect  to  the  best  situation  for  perforating,  we  find  in  books 
cautions  about  avoiding  the  chorda  tympani  nerve,  which  are  quite 
unnecessary  ;  for,  in  its  arch  across  the  tympanum,  it  is  always  far 
above  the  middle  of  the  space  either  in  front  of  or  behind  the  ex- 
tremity of  the  malleus. 

In  cases  of  permanent  thickening  and  opacity  of  the  membrana 
tympani,  which  have  resisted  all  efforts  at  absorption  and  thinning, 
are  we  justified  in  performing  perforation  ?  I  believe  in  very  few 
cases  indeed  will  it  be  found  efiicacious,  because  the  opacity  which  we 
do  see  is  but  a  portion  of  the  general  thickening  and  the  disorganiza- 
tion of  the  investing  membrane  of  the  middle  ear,  perhaps  that  of  the 
labyrinth  also,  which  we  do  not  see.  It  may,  however,  be  tried  with- 
out injury  in  some  cases,  but  it  requires  very  great  caution  and  dex- 
terity indeed  in  its  performance  ;  and,  as  irreparable  mischief  has  at 
times  proceeded  from  its  being  done  in  a  rough  or  clumsy  manner,  I 
beg  to  offer  a  few  observations  on  the  safest  method  of  performing  it. 
I  wholly  discard  all  instruments  in  the  shape  of  punches,  trochars,  and 
complicated  apparatus  for  the  removal  of  a  portion  of  the  membrane ; 
because  they  all  occupy  so  much  space  within  the  speculum  that  it  is 
not  possible  to  see  accurately  the  point  of  the  membrane  which  they 
are  pressing  upon,  nor  how  much  of  it  they  are  cutting ;  and  by  our 
not  seeing  accurately  the  surface  on  which  we  are  working,  it  is  scarcely 
possible  to  avoid  injuring  the  malleus,  or  wounding  the  inner  wall  of 
the  tympanum ;  and,  moreover,  those  with  corkscrew  points,  which 
fix  the  membrane  while  the  revolving  punch  cuts  out  the  piece,  are 
not  only  exceedingly  painful,  but  dangerous,  inasmuch  as  the  slightest 
motion  of  the  head  during  the  operation  might  produce  a  degree  of 
violence  which  would  be  destructive  to  this  delicate  structure. 

Having  brought  the  membrane  fairly  within  view,  under  bright, 

Fig.  18. 


direct  sunlight,  I  introduce  this  small,  sickle-shaped  knife, — with  a 
double-cutting  edge,  and  here  figured  of  the  natural  size  in  the  blade, 


286        PERFORATION    OF    THE    MEMBRANA    TYMPANI. 

but  with  the  shaft  and  handle  about  two  inches  longer ;  and  having 
made  the  patient  inflate  the  tympanum,  so  as  to  render  the  membrane 
tense,  and  pressed  outwards,  I  gently  introduce  the  point  of  the  knife 
into  its  inferior,  thin,  vibrating  portion,  and  drawing  it  downwards  and 
forwards,  make  a  simple  incision  of  the  membrane,  about  a  line  and  a 
half  in  length.  Occasionally  I  make  a  crucial  incision.  So  simple  is 
this,  and  so  little  pain  does  it  give,  that  the  patient  is  often  unconscious 
of  its  performance  until  made  aware  of  its  completion  by  the  air 
rushing  out  through  the  aperture.  In  about  a  minute  a  slight  oozing 
of  blood  takes  place  from  the  edges  of  the  aperture,  like  that  which 
follows  a  wound  of  the  sclerotic  with  an  ordinary  broad  cataract  needle ; 
if  left  in  this  condition  it  would  soon  heal  up  ;  therefore,  a  very  fine 
probe,  fixed  in  a  handle,  and  slightly  pointed  with  nitrate  of  silver 
by  being  immersed  in  the  caustic  when  heated  to  fluidity,  should  be 
immediately  passed  down  into  the  perforation,  the  edges  of  which  are 
thereby  cauterized  and  prevented  adhering ;  and  this  latter  process 
should  be  repeated  from  time  to  time,  as  often  as  the  wound  shoAvs  an 
inclination  to  heal,  and  until  we  establish  a  sufiiciently  large  elliptical 
opening. 

In  1846,  Dr.  Butcher,  of  this  city,  read  a  paper  before  the  Surgi- 
cal Society,  on  the  subject  of  Perforation  of  the  Membrana  Tympani, 
with  a  view  of  showing  the  ill  consequences  resulting  from  the  per- 
formance of  that  operation :  and  related  the  cases  of  two  young  per- 
sons, a  man  and  a  woman,  in  both  of  whom  it  would  appear  that  death 
ensued  from  puncturing  the  membrane.  Where  fatal  consequences 
are  said  to  result  from  an  operation  which  heretofore  has  proved,  to 
say  the  least  of  it,  innoxious,  it  is  of  very  great  importance  that  we 
should  inquire  into  all  the  circumstances  attending  such  cases,  and  the 
mode  of  performing  the  operation.  The  first  instance  was  that  of  a 
young  woman,  said  to  be  deaf  in  both  ears  for  four  years,  the  only 
history  of  whose  case  is,  that  prior  to  that  period  she  got  a  severe 
cold,  with  a  swelhng  of  the  glands  of  the  neck ;  but  what  was  the 
cause  of  her  deafness,  how  it  arose,  what  was  the  condition  of  the 
membrana  tympani,  why  the  operation  was  performed,  in  what  man- 
ner, by  whom,  or  with  what  instrument,  we  are  not  informed  ;  all  we 
know  is,  that  "  catheterism  of  the  Eustachian  tube  was  performed, 
and  said  to  fail ;  hence  it  was  agreed  upon  that  the  membrane  of  the 
tympanum  should  be  pierced,  a  small  piece  being  drilled  out  of  the 
membrane  of  the  right  side  ;"  but  we  are  not  told  any  other  circum- 
stances attending  the  operation,  nor  who  witnessed  it.     Pain  and 


PERFORATION    OF    THE    MEMBRANA    TYMPANI.         287 

other  evidences  of  inflammation  in  the  ear  ensued,  and  profuse  dis- 
charge took  place,  but  what  the  condition  of  the  ear  was  we  know  not. 
At  the  end  of  four  months  she  died,  with  symptoms  of  diseased  brain ; 
and  upon  examination  it  was  found  that  the  dura  mater  covering  the 
petrous  portion  of  the  temporal  bone  was  roughened  and  softened  in 
its  texture,  particularly  near  the  internal  auditory  foramen.  The 
membrana  tympani  was  entirely  destroyed,  and  the  lining  membrane 
of  the  tympanum  thickened  and  villous.  Noav,  while  we  are  totally 
in  the  dark  as  to  what  the  original  condition  of  this  case  was,  it  is 
manifest  that  some  great  violence  must  have  been  done  to  the  drum 
of  the  ear  in  the  performance  of  the  operation. 

The  second  case  is  equally  defective  as  to  the  cause  of  deafness  or 
the  appearance  of  the  ear,  although  the  post  mortem  examination 
was  most  interesting ;  all  Dr.  Butcher  states  is,  that  the  man  was  deaf 
for  twelve  months  previously ;  that  he  then  applied  to  a  surgeon,  and 
had  his  tympanum  pierced  (?) ;  but  why,  or  whether  with  a  gimlet  or 
a  punch,  a  trochar  or  a  probe,  we  are  not  informed.  At  first  the 
hearing  was  improved,  but  then  relapsed  ;  after  some  time  head  symp- 
toms set  in,  and  the  man  died  in  the  course  of  six  weeks.  Upon  dis- 
section, evident  traces  of  inflammation  of  the  brain  and  its  membranes 
were  discovered ;  the  dm-a  mater  in  particular,  covering  the  auditory 
portion  of  the  temporal  bone,  was  rough  and  thickened,  and  a  small 
abscess  was  discovered  in  the  anterior  lobe  of  the  brain,  upon  the 
same  side  on  which  the  perforation  was  said  to  have  been  performed. 
In  this  case,  however,  the  original  cause  of  the  deafness,  namely,  a 
small  tumor  about  the  size  of  a  bean,  lying  on  the  auditory  portion 
of  the  seventh  pair  of  nerves,  was  discovered.  This  was  evidently  a 
case  in  which  the  operation  never  should  have  been  resorted  to.  Dr. 
Butcher  deserves  much  credit  for  making  those  cases  public,  but  it  is 
to  be  regretted  that  the  statement  of  the  surgeon  who  performed  the 
operation,  whatever  it  was,  was  not  obtained,  nor  the  appearances  of 
the  ear,  both  before  and  after  the  operation,  described.  (These  cases 
are  detailed  in  the  Dublin  Medical  Press,  April  1,  1846.) 

ACCIDENTAL   PERFORATION   OF   THE    MEMBRANA    TYMPANI. 

An  aperture  of  the  membrana  tympani  may  occur  from  a  variety 
of  causes.  It  may  exist  congenitally,  it  may  happen  by  accident, 
such  as  a  penetrating  instrument,  a  foreign  body  in  the  meatus, 
loud  sudden  noises,  sneezing,  coughing,  or  blowing  the  nose,  diving 


288        PERFORATION    OF    THE    MEMBRANA    TYMPANI. 

to  any  depth,  falls  and  blows  upon  the  head,  all  of  which  have 
been  detailed  under  the  head  of  wounds  and  injuries  of  this  structure, 
at  page  218.  We  now  come  to  inquire  into  its  condition  when  per- 
forated by  disease,  the  result  of  inflammation,  &c.  An  ulcer  may  eat 
its  way  through,  and  leave  from  loss  of  substance  a  permanent  open- 
ing ;  but  the  most  frequent  cause  of  perforation  is  otitis,  or  inflamma- 
tion of  the  membrane,  in  common  with  the  lining  of  the  cavitas  tym- 
pani ;  when  the  suppuration  which  ensues,  the  pent-up  matter  bursts 
through  the  inflariied  membrane  as  the  nearest  external  outlet,  and 
the  case  is  then  one  of  otorrhoea.  I  do  not  think  the  membrana 
tympani  is  often  perforated  as  the  result  of  inflammation  confined  to 
its  own  proper  laminae. 

In  cases  of  perforation,  the  opening  is  generally  opposite  the  aper- 
ture of  the  Eustachian  tube,  which  would  rather  lead  us  to  believe 
that  it  is  caused  by  a  burst  or  rupture  of  the  membrane,  owing  to  a 
sudden  jet  of  air  striking  against  this  thin  portion  of  it  while  in  a 
state  of  inflammation  and  tension,  rather  than  that  it  was  produced 
by  either  sloughing  or  ulceration.  When  a  cornea  is  about  to  perish 
in  whole  or  in  part  from  sloughing,  hypopyum,  or  penetrating  ulcer, 
we  have  an  opportunity  of  observing  the  process  from  hour  to  hour. 
It  is  not  so,  however,  in  cases  of  inflammation  of  the  ear ;  we  have 
seldom  an  opportunity  of  examining  the  part  until  the  mischief  has 
occurred.  When  the  disease  happens  during  measles  or  scarlatina, 
the  ordinary  medical  attendant  pays  but  little  attention  to  the  state 
of  the  ears,  although  the  patient  frequently  complains  of  excruciating 
pains  therein.  He  is  satisfied  with  attending  to  the  state  of  the  fever 
and  the  eruption,  telling  the  friends  that  the  aural  afiection  can  be 
easily  rectified  after  the  patient's  recovery.  It  must,  however,  be 
acknowledged,  that  in  many  instances  the  general  symptoms  of  the 
disease  are  of  such  a  threatening  character,  that  both  the  physician 
and  the  friends  are  well  satisfied  if  the  patient  escapes  with  life. 
Nevertheless,  I  cannot  but  feel,  that  an  examination  with  the  specu- 
lum should  be  made  in  all  such  cases,  and  means  taken  to  relieve  the 
aural  disease  by  the  application  of  a  few  leeches,  &c.  I  have  fre- 
quently saved  eyes  in  patients  laboring  under  small-pox,  by  employ- 
ing the  ordinary  remedies  applicable  to  pustules  in  the  cornea. 

In  cases  of  inflammation  of  the  middle  ear  and  membrana  tympani, 
we  will  generally  find,  upon  examination,  that  the  latter  is  one  uni- 
form sheet  of  redness,  without  any  appearance  of  pointing,  sloughing, 
or  ulceration ;  and,  within  a  few  hours  after,  the  patient  will  tell  us 


PERFORATION    OF    THE    MEMBRANA    TYMPANI.        289 

that  he  is  relieved  of  his  pain  by  something  having  suddenly  burst  in 
his  ear,  and  then,  upon  inspection,  we  find  an  opening  in  the  mem- 
brana  tympani. 

In  perforation,  particularly  if  the  aperture  is  large,  the  patient 
generally  complains  of  some  of  the  water  getting  into  the  throat  in 
syringing. 

At  page  144,  I  have  already  remarked  upon  the  general  characters 
and  most  usual  position  of  the  aperture  in  the  membrane.  Where 
there  is  no  obstruction  in  the  meatus,  we  can,  by  directing  a  stream 
of  strong  sunlight  through  the  speculum,  easily  detect  the  rupture, 
unless  it  is  either  very  small  or  valvular.  If  of  long  standing,  its 
edge  is  generally  red  and  thickened,  and  the  space  behind  it  is  usually 
very  dark,  but  we  cannot  be  certain  of  the  precise  color  unless  the 
aperture  is  of  a  moderate  size.  When  a  large  portion  of  the  mem- 
brane has  been  removed,  as  is  often  the  case  in  ears  long  affected  with 
otorrhoea,  we  can  with  facility  perceive  the  color  of  the  mucous  mem- 
brane of  the  tympanum,  which,  from  its  exposure,  and  the  state  of 
chronic  irritation  in  which  it  must  be,  is  usually  thickened,  often 
granular,  and  always  of  a  deep  bright  red ;  and,  moreover,  the  edge 
of  the  aperture  throws  a  dark  shadow  upon  the  inner  wall  of  the  tym- 
panum beyond,  which  we  can  alter  by  changing  the  position  of  the 
head  or  the  speculum,  in  the  same  way  that  a  shadow  is  seen  between 
the  margin  of  the  pupil,  and  an  opaque  lens  behind,  if  the  two  are 
not  in  contact.  In  cases  of  extensive  destruction  of  the  membrane, 
where,  upon  introducing  the  speculum,  we  merely  observe  a  florid  red 
vascular  surface,  an  unpractised  eye  may  find  it  difficult  to  determine 
by  mere  inspection  whether  the  surface  brought  into  view  at  the 
bottom  of  the  meatus  is  the  surface  of  a  carneous  membrana  tympani 
or  the  inner  wall  of  the  tympanum  itself.  The  difference  can  at  once 
be  distinguished  by  passing  down  a  fine  probe,^  and  gently  percus- 
sing the  surface  vfe  are  looking  at^  and  if  it  be  that  of  the  tympanum, 
a  delicate  touch  at  once  detects  the  difference  of  texture ;  while,  if 
the  contrary,  the  patient  is  always  conscious  of  something  knocking 
against  the  skull,  but  generally  complains  less  than  if  the  probe 
touched  the  membrana  tympani.  The  part  most  usually  presented  is 
the  promontory. 

'  When  we  have  occasion  to  use  a  probe  for  examining  the  ear,  it  should  be  about 
three  inches  long,  fixed  in  a  handle,  have  rather  a  large  button  on  the  end,  and  be  very 
slender  for  about  an  inch  behind  the  extremity,  so  that  it  will  bend  with  facility  should 
the  patient  move  the  head  in  the  direction  of  the  instrument. 

19 


290        PERFORATION    OF    THE    MEMBRANA    TYMPANI. 

When  the  membrane  has  been  eaten  away  by  ulceration,  or  so 
much  of  its  lower  portion  destroyed  by  rupture  or  other  circumstances 
as  to  cease  to  be  a  fixed  point  for  the  manubrium  of  the  malleus,  the 
ossicula,  or  at  least  whatever  remnant  of  them  remains,  are  drawn 
upwards  and  backwards,  and  generally  present  with  the  portion  of 
the  membrane  a  well-defined  protuberance,  generally  whiter  than  the 
remaining  parts. 

Where  we  have  any  difficulty  in  detecting  an  aperture,  we  should 
direct  the  patient  to  force  air  into  the  drum,  when  the  squeeling, 
gurgling,  or  whistling  sound,  produced  by  its  transit  through  the  rup- 
ture, will  decide  the  question, — supposing  the  Eustachian  tube  to  be 
free,  which,  in  some  cases,  it  is  not.  When,  in  cases  of  recent  otitis, 
the  meatus  is  thickened,  and  both  it  and  the  external  surface  of  the 
membrana  tympani  covered  with  a  layer  of  white  macerated  cuticle 
and  flakes  of  discharge,  it  is  sometimes  difficult,  by  mere  inspection 
alone,  to  decide  the  question,  particularly  if  direct  sunlight  is  not 
available  at  the  moment.  Some  time  ago,  I  described  two  diagnostic 
symptoms,  one  or  other  of  which,  when  present,  are  unfailing  indica- 
tions of  rupture.  If,  on  looking  into  the  meatus,  even  without  a 
speculum,  we  see  a  single  globule  of  air  entangled  in  the  discharge 
which  generally  fills  it,  we  may  rest  assured  that  the  tympanal  cavity 
is  open  externally.  If  we  do  not  at  first  see  this  globule,  and  that 
we  press  upon  the  root  of  the  tragus  with  the  point  of  the  finger, 
we  can  generally,  if  the  tympanum  is  open,  bring  it  to  the  surface. 
I  suppose  it  is  forced  up  through  the  Eustachian  tube  in  sneezing  or 
coughing,  &c.,  and  finds  its  way  from  the  tympanal  cavity  to  the  sur- 
face of  the  fluid.  Sometimes  several  air-bubbles  fill  the  bottom  of  the 
meatus,  which  generally  coalesce  upon  the  introduction  of  the  specu- 
lum. Some  years  ago,  I  was  called  to  see  a  gentleman  said  to  be 
laboring  under  fever ;  he  was,  from  the  commencement,  extremely 
deaf,  and  had  complained  of  violent  pain  in  his  ears  and  head  ;  he 
had  great  heat  of  skin,  loss  of  rest,  a  brown  furred  tongue,  great 
thirst,  some  intolerance  of  light,  a  very  quick  pulse,  and  other  febrile 
symptoms.  Upon  the  fifth  day  a  purulent  discharge  was  observed 
to  issue  from  both  his  ears,  when  the  attention  of  the  medical  atten- 
dant was  first  attracted  to  the  organs  of  hearing.  I  saw  him  upon 
the  sixth  day;  he  was  then  so  deaf  that  he  had  to  be  communicated 
with  by  writing.  On  examination,  I  found  several  air-bubbles  mixed 
with  the  discharge  which  poured  from  his  ears ;  and  I  at  once  stated 
to  the  practitioner  in  attendance,  what  subsequently  proved  to  be 


PERFORATION    OF    THE    MEMBRANA    TYMPANI.        291 

correct,  that  the  case  was  one  of  otitis,  in  which  the  tympanal  mem- 
branes had  given  way  to  allow  exit  to  the  pent-up  pus.  From  the 
condition  of  the  patient  at  the  time  I  saw  him,  it  was  not  possible  to 
make  an  accurate  examination,  neither  was  such  at  the  moment  neces- 
sary. Two  days  afterwards,  upon  removing  the  discharge,  an  aper- 
ture was  found  in  the  antero-inferior  part  of  the  membrana  tympani, 
opposite  the  Eustachian  tube,  on  each  side.  These  apertures  subse- 
quently closed,  and  the  gentleman  recovered  his  hearing.  I  have  re- 
marked that  a  rupture  of  the  membrane,  produced,  like  this,  from 
otitis,  heals  more  readily,  and  often  without  treatment,  than  that  pro- 
duced by  chronic  otorrhcea;  the  former  being  a  rupture,  the  latter  an 
ulcer,  and,  consequently,  attended  with  a  greater  loss  of  substance. 
While  correcting  these  pages,  I  was  consulted  by  a  lady  for  deafness 
of  the  left  ear.  Upon  examining  the  right,  about  which  she  made  no 
complaint,  I  found  the  membrana  tympani  thickened  and  opaque, 
except  one  abnormally  thin  portion  in  the  centre,  which  was  rather 
depressed  beneath  the  surrounding  surface.  Upon  expressing  an 
opinion  that  she  must  have  had  some  inflammatory  action  in  that  ear 
previously,  she  acknowledged  that,  nineteen  years  before,  she  had 
had  a  "severe  bleeding"  which  kept  her  awake  several  nights,  until 
relieved  by  a  discharge  of  matter,  which  continued  to  flow  from  her 
ear  for  some  months  subsequently.  I  suppose  the  rent  was  filled  up 
by  the  delicate  bit  of  membrane  still  apparent  in  the  centre  of  the 
drum-head. 

Another  cui'ious  phenomenon,  which  has  not,  as  far  as  I  am  aware, 
been  pre^^ously  described  by  authors,  is, — that,  when  the  membrane 
is  perforate,  and  that  an  air  globule  exists  at  the  bottom  of  the 
meatus,  we  can,  by  keeping  the  eye  steadily  fixed  upon  it, — and  as 
its  bright  convex  surface  generally  reflects  the  light,  it  is  easily  seen, — 
perceive  that  it  pulsates,  and  that  its  action  is  synchronous  with  that 
of  the  heart  and  arteries.  It  is  not  an  invariable  symptom,  and  the 
pulsation  sometimes  intermits.  In  order  to  see  it  in  perfection,  there 
ought  to  be  but  a  slight  coating  of  thin  discharge  at  the  bottom  of 
the  meatus,  and  the  globule  from  which  the  light  is  thus  brilliantly 
reflected  should  be  either  entangled  in  or  opposite  the  opening  in  the 
membrana  tympani.  In  most  of  the  cases  in  which  I  have  remarked 
it,  the  aperture  was  rather  small,  and  situated  in  the  posterior  part 
of  the  membrane.  I  have  never  seen  it  where  the  opening  was  very 
large,  or  the  membrane  entirely  destroyed.  It  is  an  additional  proof 
that  the  membrane  pulsates,  certainly  in  disease,  and  probably  in  a 


292       PERFORATION    OF    THE    MEMBRANA    TYMPANI. 

normal  condition  also ;  although  we  are  not  in  a  position  to  detect  its 
motion.  (See  additional  remarks  upon  this  subject  at  page  216.) 
As  already  stated,  the  rupture  usually  takes  place  in  the  anterior 
portion,  and  close  to  the  opening  of  the  Eustachian  tube ;  sometimes 
it  may  be  seen  as  a  round  or  oval  hole,  about  the  size  of  No.  8  shot, 
and  appearing  as  if  punched  out  of  the  membrane.  In  other  in- 
stances it  occurs  at  the  anterior  inferior  edge  of  the  membrane,  in 
which  case  the  lower  margin  of  the  aperture  is  formed  by  the  parietes 
of  the  canal  and  cavity  of  the  tympanum.  In  still  rarer  instances 
the  rupture  takes  place  in  the  posterior  division  of  the  membrane, 
below,  and  somewhat  behind,  the  point  of  the  malleus.  Sometimes 
the  aperture  presents  a  kidney  shape  round  the  manubrium,  which 
projects  into  it  like  a  peninsula. 

The  treatment  of  an  aperture  in  the  membrana  tympani,  and  the 
success  which  is  likely  to  attend  it,  must  depend  upon  its  cause,  dura- 
tion, and  extent :  the  older,  the  less  likely  to  heal,  and  if  from  ulce- 
ration, it  is  also  more  unpromising  than  when  it  has  taken  place  from 
mechanical  injury  or  the  pressure  of  accumulated  fluid. 

An  aperture,  even  of  considerable  size,  may  exist  in  the  membrana 
tympani,  without  otorrhoea,  but  upon  the  slightest  accession  of  cold, 
otorrhoea  will  occur  from  the  surface  of  the  exposed  tympanal  cavity. 
The  prognosis  is  uncertain.  I  have  sometimes  failed  in  healing  very 
small  apertures,  while  much  larger  ones  have,  to  my  surprise,  closed, 
under  treatment,  in  a  very  short  time. 

After  a  long  and  fair  trial  of  several  means  proposed  for  healing 
apertures  in  the  membrana  tympani,  I  have  come  to  the  conclusion, 
that  there  is  nothing  like  nitrate  of  silver.  It  Avill  not,  however, 
answer  to  thrust  a  stick  of  lunar  caustic,  fastened  in  a  quill,  down 
the  meatus,  for  the  purpose  of  touching  any  part  of  the  membrana 
tympani ;  to  be  used  with  effect,  the  escharotic  should  be  applied  upon 
the  extreme  edge  of  the  aperture,  or  rather  within  the  ring  of  the 
opening,  every  second  or  third  day,  so  long  as  the  part  seems  inclined 
to  close,  but  the  moment  we  perceive  it  enlarging,  a  day  or  two  after 
the  application,  we  must  desist.  As  it  is  not  always  possible  to  reduce 
a  pencil  of  nitrate  of  silver  to  the  requisite  degree  of  fineness,  I  have, 
for  several  years  past,  been  in  the  habit  of  pointing  probes  and  other 
instruments  used  in  minor  sm-gery,  with  nitrate  of  silver  attached  to 
them,  in  the  following  manner : — a  portion  of  the  caustic  is  to  be 
melted  to  the  boiling  point,  in  a  small  silver  or  platina  ladle,  such  as 
that  represented  below,  held  over  a  spirit  lamp.     When  the  caustic  has 


PERFORATION    OF    THE    MEMBRANA    TYMPANI.        293 

become  quite  clear,  the  point  of  the  probe  or  instrument  to  which  it 
is  to  be  attached  should  be  heated  in  the  flame  of  the  lamp,  and  then 

Fig.  19. 


^ 


dipped  into  the  fluid  caustic  several  times,  until  a  sufiicient  quantity 
is  taken  up.  B  j  this  means,  we  can  point  a  needle  with  caustic,  should 
it  be  necessary  to  apply  it  to  any  minute  part,  such  as  an  ulcer  on 
the  eye,  &c.^     The  instrument  figured  below  will  be  found  very  con- 


c 


venient  for  applying  nitrate  of  silver  to  any  surface  within  the  meatus. 
This  porte-eaustic  is  about  six  inches  long,  and  consists  of  a  silver 
tube,  cut  spirally  for  three-fifths  of  its  length,  and  having  an  aperture 
in  the  side,  or  a  hollow  at  end.  When  about  to  be  used,  its  extremity 
should  be  coated  with  caustic,  as  already  directed.  The  elastic  spring 
prevents  any  injury  to  the  ear  from  the  starting  of  the  patient,  and  can 
also  be  bent,  so  as  to  be  applied  with  ease  to  any  part  of  the  auditory 
canal.  When  granulations  sprout  from  a  perforation  in  the  mem- 
brane— which  is  very  rare,  unless  the  rupture  occurs  immediately 
adjoining  its  edge — this  mode  of  applying  caustic  will  be  found  very 
effectual,  as  well  as  for  the  eradication  of  small  polypi ;  but  I  have 
never  yet  seen  a  polypus  attached  to  the  membrana  tympani. 

When  the  membrana  tympani  is  perforated,  and  that  we  touch  it, 
or  a  polypous  gi'owth,  or  sometimes  even  an  abraded  spot  upon  the 
surface  of  the  meatus,  with  solid  nitrate  of  silver,  it  is,  in  many  cases, 
tasted  in  the  mouth  almost  immediately,  but  only  on  the  side  to  which 
it  has  been  applied.  Patients  say,  "  they  feel  the  impression  of  the 
caustic  running  down  along  that  side  of  the  tongue,  but  not  reaching 

*  Dr.  MDonnell,  of  Montreal,  formerly  of  Dublin,  wrote  an  article  in  the  Medical 
Journal  of  that  city  some  years  ago,  to  shovj  that  I  was  not  the  original  inventor  of  this 
ingenious  application  of  this  very  ,i\seful  remedy,  and  that  Dr.  Morgan  of  this  city  was 
the  person  to  whom  the  credit  belongs.  When,  in  January,  1844,  I  first  recommended 
it,  I  feel  sure  that,  if  I  had  remembered  Dr.  Morgan's  suggestion,  I  would  have  men- 
tioned it,  as  I  have  all  my  life  labored  to  "  render  tribute  to  whom  tribute  is  due ;"'  and 
I  therefore  take  this  opportunity  of  rendering  my  townsman  due  credit  for  the  suggestion, 


294        PERFORATION    OF    THE    MEMBRANA    TYMPANI. 

the  lip."  I  never  knew  this  peculiarity,  except  where  there  was  a 
hole  in  the  membrane.  Is  it  transmitted  bj  continuity  of  mucous 
surface,  or  by  means  of  the  chorda  tympani  ? 

The  following  case,  No.  2  in  the  Registry,  of  chronic  thickening 
of  the  left,  and  total  loss  of  the  right,  membrana  tympani,  will  be 
found  illustrative  of  the  foregoing  observations  : — 

E.  S.,  a  female,  aged  25,  suffered  from  disease  of  the  ears  since 
she  had  scarlatina,  three  or  four  years  ago;  has  had  "a  running" 
from  one  ear,  but  never  experienced  any  pain  on  either  side,  and 
never  had  medical  advice.  A  constant  buzzing  noise  is  present  in 
the  left  ear ;  none  whatever  in  the  right.  Hearing  distance  on  the 
right  side,  five  inches ;  on  the  left  only  on  pressing  the  watch  to  the 
external  ear;  hears  the  watch  well  on  placing  it  between  the  front 
teeth.  Upon  examination,  we  find  chronic  inflammation,  attended 
with  muco-purulent  discharge,  in  the  right  ear.  On  bringing  the 
bottom  of  the  meatus  auditorius  into  view,  we  perceive  a  smooth, 
deep-red,  moist,  and  irregularly  concave  surface :  this  is  the  inner 
wall  of"  the  tympanum,  the  mucous  membrane  covering  which,  by 
being  so  long  exposed  to  the  atmosphere,  has  assumed  this  peculiar 
florid  and  villous  appearance.  The  eye  informs  us  that  we  are  not 
looking  at  the  membrana  tympani ;  the  peculiar  curve  of  the  surface 
that  meets  the  view,  the  hue  of  color,  and  the  great  depth  at  which 
it  is  placed,  would,  even  if  one  were  not  well  acquainted  with  the 
appearance,  at  once  lead  us  to  say  that  the  membrane  had  been  re- 
moved ;  and,  on  passing  down  a  fine  round-headed  probe,  it  knocks 
against  the  bony  protuberance  of  .the  promontory.  The  spot  where 
the  probe  touched  has  become  of  a  much  deeper  red,  and  the  patient 
says  she  experienced  a  sensation  as  if  something  was  knocking  loudly 
against  the  side  of  her  head.  Towards  the  upper  and  posterior  side 
there  is  a  white  projection,  the  displaced  malleus,  from  which  a 
shadow  is  thrown  upon  the  red  surface  of  the  tympanal  cavity.  The 
shadow  thrown  from  it  proves  that  it  is  not  in  contact  with  the  deep 
surface  we  are  looking  at :  in  the  same  way  as  the  shadow  cast  by  the 
pupillary  margin  of  the  iris  tells  us  the  position  of  the  opacity,  and 
other  circumstances  of  great  importance,  in  a  practical  point  of  view, 
in  cases  of  cataract.  Towards  the  lower  and  anterior  edge  of  the 
cavity  may  be  observed  a  spot  darker  than  the  rest,- — the  aural  open- 
ing of  the  Eustachian  tube, — but  the  patient  is  unable  to  pass  air 
through  it.  When  this  tympanal  membrane  was  destroyed  we  know 
not ;  probably  an  aperture  occurred  in  it  during  the  scarlet  fever, 


AETIFICIAL    MEMBRANA    TTMPANI.  295 

from  which  she  suffered  at  the  time  her  deafness  came  on,  and,  by 
ulceration,  it  has  since  extended.  I  am  inclined  to  think  this  has 
been  the  j)rocess ;  for  she  says  the  discharge  under  which  she  formerly 
labored,  and  which  was  so  great  as  to  pour  out  of  the  external  meatus 
and  soil  her  dress,  has  of  late  considerably  lessened,  and  is  now  very 
slight,  and  about  the  consistence  of  made  starch.  This  accords  with 
my  experience  of  those  discharges.  In  cases  of  polypus,  without  any 
aperture  in  the  tympanal  membrane,  the  discharge  is  always  profuse, 
and  usually  purulent ;  where  there  is  an  aperture  in  the  membrane,  it 
is,  generally  speaking,  not  so  abundant,  but  more  mucous  ;  and  where 
the  membrane  has  been  almost  entirely  removed,  as  in  this  case,  the 
discharge  frequently  lessens.  Sometimes  there  is  scarcely  sufficient 
secretion,  and  patients  are  in  the  habit  of  moistening  the  ear  with  a 
drop  of  water  applied  with  the  end  of  the  finger.  I  know  a  gentle- 
man who  does  so  every  day  after  dinner  when  he  wishes  to  hear 
well,  and  he  has  an  aperture  in  his  membrana  tympani.  As  already 
stated,  this  patient  has  no  noise  upon  this  (the  right)  side.  When 
the  membrane  has  a  large  aperture  in  it,  or  has  been  completely  re- 
moved, I  have  generally,  but  not  invariably,  observed,  that  there  is 
no  tinnitus  aurium,  or,  if  such  existed  upon  the  first  accession  of  deaf- 
ness, it  ceases  as  soon  as  the  membrane  has  become  so  much  destroyed 
as  in  this  case,  unless  it  had  been  originally  cerebral.  Therefore  it 
is  that  some  persons  have  derived  relief  from  this  most  distressing 
symptom  by  having  the  membrane  perforated,  although  the  removal 
of  the  deafness  could  not  be  expected. 

This  woman  hears  at  five  inches  distance  upon  the  right  side ;  but 
she  hears  the  voice  better  than  other  persons  who  possess  a  hearing 
distance  by  the  watch  of  some  inches  more  :  this  is  worthy  of  remark, 
and  applies  to  a  vast  number  of  deaf  cases.  Some  persons  are  better 
able  to  understand  the  purport  of  discourse  from  a  natural  quickness 
of  comprehension,  and  will  maintain  a  conversation  although  they 
cannot  hear  the  watch  at  two  inches  distance ;  while  others  who  hear 
the  watch  at  three  times  that  distance  exhibit  a  dulness  of  general 
hearing  that  is  quite  remarkable.  I  have  observed  that,  when  once 
the  tympanal  membrane  has  become  permanently  open,  the  larger 
the  aperture,  the  greater  the  amount  of  hearing,  provided  that  no 
further  mischief  has  taken  place,  and  that  there  is  a  slight  ring  or 
circle  of  the  membrane  still  remainino-. 

Artificial  Membrana  Tympani. — A  complete  cure  for  deafness 
arising  from  an  aperture  of  the  tympanal  membrane,  by  passing  a 


296  ARTIFICIAL    MBMBRANA    TYMPANI. 

portion  of  wool  or  raw  cotton,  moistened  with  some  fluid,  into  the 
bottom  of  the  meatus,  was  published  in  July,  1848.  I  became  aware 
of  the  fact  about  eight  years  ago,  through  a  lady  resident  in  Clonmel, 
who  discovered  it,  she  told  me,  by  accident.  Considering  hers  an 
isolated  case,  an-d  having  my  attention  directed  particularly  to  other 
subjects  at  the  moment,  I  thought  no  more  about  the  matter  then. 
The  lady  informs  me,  in  answer  to  a  recent  communication,  that  the 
disease  in  her  ears  originated  in  what  she  styles  brain  fever,  eighteen 
years  ago,  but  that  the  physicians  whom  she  consulted  told  her  that 
her  aural  affection  was  merely  nervousness,  and  that  the  drums  of  her 
ears  were  quite  unaffected.  "Suffering,"  she  says,  "so  dreadfully 
from  deafness,  and  a  suffocating  feel  about  my  head,  I  resorted  to 
many  experiments.  At  last  I  was  recommended  to  try  a  piece  of  fat 
bacon,  toasted  over  a  candle,  and  then  put  into  the  ears.  I  used  it 
for  a  long  time,  but  eventually  I  was  obliged  to  discontinue  it,  as  it 
hurt  me  very  much.  I  then  dropped  oil  into  my  ears  instead,  and 
it  for  awhile  enabled  me  to  hear,  but  in  an  hour  or  two  afterwards  I 
used  to  "be  as  deaf  as  ever ;  so  I  naturally  thought  that,  by  putting  a 
little  wool  with  the  oil  into  my  ear,  and  thus  keeping  up  the  moisture, 
it  would  answer  the  purpose.  This  I  tried,  and  found  it  most  effica- 
cious. I  must,  however,  have  it  settled  in  one  particular  spot  in  my 
ear,  or  it  would  be  quite  useless,  and  were  I  to  take  it  out  I  would 
not  hear  a  word.  I  generally  arrange  it  with  a  large  pin  or  bodkin, 
and,  when  fixed  properly,  I  have  no  occasion  to  change  it  for  three 
days  together." — A.  M'S. 

To  Mr.  Yearsley  we  are,  however,  indebted  for  making  this  valua- 
ble discovery  known,  as  already  stated  at  page  47 ;  and  although 
Deleau  and  others  have  claimed  acquaintance  with  the  fact,  it  is 
manifest  that  they  made  no  use  of  it.^  The  subject  is  one  that  has 
lately  engaged,  and  very  justly,  much  attention,  and  I  have  recently 
verified  in  numerous  cases  the  opinion  which  I  have  on  a  former  occa- 
,  sion  expressed  of  its  value. 

A  gentleman,  about  fifty  years  of  age,  caught  a  violent  cold  by 
being  much  exposed  dm"ing  the  night  air  among  some  of  the  snowy 
mountains  and  glaciers  of  Switzerland  a  year  and  a  half  previous  to 
the  time  I  sa,w  him.  He  was  attacked  with  dull  aching  pains  in  his 
ears,  attended  with  considerable  deafness.  He  said — and  being  a 
person  of  great  intelligence  and  some  scientific  acquirements,  I  was 

«  See  Medical  Times  for  12th  April,  1851,  p.  412. 


ARTIFICIAL    MEMBEANA    TTMPANI.  297 

constrained  to  believe  his  statement — that,  upon  applying  for  advice 
in  one  of  the  large  towns  in  Switzerland,  a  mixture  containing  mu- 
riatic acid  was  prescribed  for  him,  in  order  to  "  alleviate  the  pain 
and  stimulate  the  drum  of  his  ears/'  Shortly  after  the  first  applica- 
tion, which,  unfortunately,  was  made  on  both  sides,  he  had  a  violent 
attack  of  earache,  which,  he  states,  "nearly  set  him  mad,"  but  that 
he  got  relief  as  soon  as  something  bm'st  in  his  ears,  and  that  a  dis- 
charge was  established.  Having  heard  of  the  glycerine-and- cotton 
remedy,  he  applied  it,  and  succeeded  once,  but  never  after,  in  gaining 
relief.  Upon  inquiry,  I  found  that  he  had  completely  filled  the 
meatus  with  a  plug  of  wool  and  glycerine.  On  examination,  I  found 
that  the  tympanal  membrane  had  been  altogether  removed  upon  one 
side,  and  but  a  slight  remnant  of  it  remained  upon  the  other.  He 
had  a  good  deal  of  discharge  ;  no  noise  :  but  he  was  so  deaf  that  one 
required  to  shout  to  him  ;  and  he  came  to  me  to  recommend  him 
some  sort  of  hearing-trumpet.  The  mucous  membrane  of  the  t^^m- 
panal  cavity  and  the  meatus  were  in  a  state  of  chronic  inflammation, 
which,  being  lessened  by  the  application  of  a  solution  of  nitrate  of 
silver  and  other  means  employed  for  a  few  days,  I  introduced  bits  of 
moistened  cotton  in  the  manner  previously  described.  His  hearing 
was  instantaneously  restored ;  and,  having  taught  him  after  a  few 
visits  how  to  manage  the  application  himself,  he  was  again  able  to 
join  society  almost  as  well  as  ever. 

Highly  valuable,  however,  as,  no  doubt,  this  remedy  is,  it  is,  in  its 
application  and  usefulness,  variable.  In  some  cases  what  it  will  efi'ect 
is  quite  marvellous, — almost  instantaneous  restoration  to  comfortable 
hearing ;  but,  in  other  instances,  it  does  not  succeed  so  well,  or  even 
at  all.  The  cases  in  which  it  is  most  effectual  are  those  where  there 
is  a  very  large  aperture  in,  but  not  a  total  destruction  of,  the  mem- 
brana  tympani.  It  requires  some  tact  to  hit  off  the  exact  position 
in  which  to  place  the  bit  of  cotton ;  but,  the  moment  it  is  done,  either 
by  the  practitioner  or  the  patient,  the  hearing  is  restored.  It  should 
be  made  to  fit  on  or  into  the  aperture  in  the  membrane,  not  com- 
pletely to  block  up  the  meatus,  nor  to  press  against  the  inner  wall  of 
the  tympanum.  It  ought  to  be  passed  down  with  a  fine  forceps  or 
probe,  and  patients  should  be  taught  how  to  introduce  it  themselves  ; 
the  lady  by  whom  I  first  saw  it  employed  always  carried  a  bodkin,  a 
little  fine  wool,  and  a  bottle  of  oil,  for  the  purpose.  I  do  not  think 
it  matters  much  what  the  fluid  is  ;  I  generally  use  fine  oil,  and,  after 
the  bit  of  cotton  is  saturated  with  it,  I  press  it  gently  between  the 


298  ARTIFICIAL    MEMBRANA    TYMPANI. 

fingers.  As  there  is  always  some  discharge  from  the  exposed  mucous 
membrane  in  these  cases,  a  sufficient  moisture  is  kept  up  for  two  or 
three  days ;  but  the  wool  or  cotton  should  be  removed  from  time  to 
time,  according  to  the  patient's  own  sensations,  and  never  allowed  to 
remain  in  longer  than  three  or  four  days.  If  there  be  much  discharge 
present,  the  wool  or  cotton  may  require  removal  daily.  It  is  asto- 
nishing with  what  adroitness  a  patient  will  sometimes  hit  off  the 
necessary  position  of  the  cotton,  even  after  the  practitioner  has  failed 
to  adjust  it.  Notwithstanding  some  ingenious  attempts  at  explana- 
tion, we  still  require  a  feasible  solution  as  to  how  this  remedy  acts. 

Mr.  Toynbee  has  recently  recommended  a  thin  plate  of  vulcanized 
India  rubber  or  gutta  percha,  attached  to  a  wire  stem,  as  an  artificial 
tympanic  membrane,  in  lieu  of  the  wool  or  cotton  remedy.^  I  have 
no  experience  of  it ;  but  I  doubt  its  general  applicability. 

In  the  foregoing  chapter  I  may  to  some  have  appeared  prolix  ;  but, 
upon  a  subject  comparatively  so  new  in  English  literature,  so  little 
studied,  and  consequently  so  little  understood  by  practitioners  in 
general;  it  was  not  possible  to  explain  my  meaning  without  entering 
into  minute  descriptions.  Moreover,  from  the  circumstance  of  the 
membrana  tympani  being  the  part  most  easily  examined,  being  that 
most  frequently  afi"ected,  and,  consequently,  afibrding  the  safest 
means  for  diagnosis  either  for  deafness  arising  from  affections  pecu- 
liar to  itself,  and  confined  to  its  own  structure,  or  which  it  exhibits 
in  common  with  other  and  deeper-seated  structures  similarly  diseased, 
it  frequently  afi"ords  us  not  only  the  surest  but  the  only  faithful  indi- 
cation for  forming  an  accurate  diagnosis.  If  aural  diseases  were  as 
attentively  studied  in  these  kingdoms  as  ophthalmic  or  obstetric 
afiections,  then  would  the  lengthened  description  of  cases  be  unneces- 
sary; but  where  do  we  find,  throughout  the  whole  circle  of  our 
periodical  literature,  half-a-dozen  well  observed  and  accurately  noted 
cases  of  disease  of  the  ear  in  a  twelvemonth  ?  Faithful  observation 
and  clinical  records  of  disease  are  now  more  required  in  this  than  in 
any  other  branch  of  medical  science. 

'  See  Medical  Times  and  Gazette  for  February  12th,  1853. 


299 


CHAPTER   VL 


DISEASES   OF   THE   MIDDLE   EAR   AND    EUSTACHIAN   TUBE. 

Anatomy  of  the  Cavitas  Tympani. — Apertures,  Ossicula,  and  Investing  Membrane. — 
The  Eustachian  Tube  and  Tonsils.— Congenital  Malformations  of  the  Middle  Ear. — 
Wounds  and  Injuries;  Hemorrhage  and  Serous  Effusion. —  Inflammations:  Acute 
Otitis  ;  Otorrhcea  :  Subacute  Otitis  :  Exanthematous  and  Typhoid  ;  Acquired  Dumbness  ; 
Facial  Paralysis. — Rheumatic  Otitis  ;  Periosteal ;  Caries. — Diseases  of  Mastoid  Cells. — 
Affections  of  the  Ossicula. — Morbid  Growths  in  the  Tympanum  ;  Polypus  ;  Exostosis. — 
Catarrhal  and  Chronic  Otitis  ;  Ablution,  Fumigation,  and  Bougie  Exploration  of  Tympa- 
num.— Malignant  Fungus. — Diseases  of  the  Eustachian  Tube  ;  Foreign  Bodies  in  ;  In- 
flammation ;   Obstruction. — Throat  Deafness. — Enlarged  Tonsils  and  Cleft  Palate. 

Although  I  liave  separated  the  diseases  of  the  Eustachain  tube 
from  those  of  the  cavitas  tympani  in  the  Nosological  Table  in  accord- 
ance with  the  anatomical  basis  observed  in  their  general  division  ;  still, 
in  a  pathological  point  of  view,  these  two  parts  may  as  fairly  be 
classed  together  as  the  diseases  of  the  middle  ear  and  the  mastoid 
cells. 

The  middle  division  of  the  auditory  apparatus,  the  tympanum  or 
cavitas  tympani,  is  that  space  between  the  membrana  tympani  exter- 
nally, which  separates  it  from  the  auditory  tube,  and  the  outer  wall 
of  the  internal  ear  or  labyrinth.  It  resembles  the  form  of  its  exter- 
nal septum,  but  is  rather  more  irregular  in  its  circumferential  bound- 
ary. It  is  somewhat  wedge-shaped,  being  narrow  below  and  broad 
above,  owing  to  the  oblique  position  of  the  membrana  tympani,  and 
measures  about  three-eighths,  or  from  that  to  half  an  inch  in  its  longest 
diameter.  In  the  dry  bone  it  has  five  special  outlets, — externally 
into  the  osseous  meatus ; — internally  by  two  small  apertures,  which 
communicate  with  the  labyrinth,  called  from  their  shape  the  round 
and  the  oval  window, — two  proceeding  from  the  circumference  ;  of 
these,  that  anteriorly,  and  a  little  below  the  middle  horizontal  line,  is 
the  entra;nce  of  the  Eustachain  tube,  which  communicates  with  the 
throat ;  and  one  or  more  openings  lead  in  the  adult  into  the  mastoid 


300  ANATOMY    OF    THE    CAVITAS    TYMPANI. 

cells  superiorly  and  posteriorlj.  Viewed  from  without,  by  making  a 
section  of  the  temporal  bone  immediately  beyond  the  groove  for  the 
attachment  of  the  membrana  tympani,  we  observe  upon  its  inner  wall 
a  projection  of  densely  hard  bone  dividing  the  two  apertures  already 
alluded  to,  both  of  which  are  placed  in  the  posterior  half,  and  conse- 
quently immediately  opposite  the  external  outlet  of  the  osseous  audi- 
tory canal  and  the  posterior  vibrating  portion  of  the  membrana  tym- 
pani. This  protuberance  is  the  promontory  caused  by  the  projection  of 
the  cochlea :  the  inferior  opening  is  the  fenestra  rotunda,  somewhat 
triangular  in  shape,  and  in  the  recent  state  closed  by  a  delicate  mem- 
brane analogous  to  the  membrana  tympani,  and  which  may  be  called  the 
internal  drum-head,  which  separates  the  tympanum  from  the  extremity  of 
the  cochlea,  and  hence  called  the  fenestra  cochleae.  As  this  membrane 
serves  to  transmit  vibrations  of  sound,  and  is  the  only  barrier  to  the 
escape  of  the  fluid  contained  within  the  labyrinth,  it  is  manifest  that 
any  interference  with  its  functions,  any  alterations  or  organic  changes 
in  its  structure,  or  its  total  destruction  from  sloughing,  ulceration,  or 
caries  of  its  bony  attachment,  must  be  attended  with  considerable  impair- 
ment, if  not  total  loss  of  hearing.  When  the  tympanic  cavity  is  exposed 
by  extensive  destruction  of  its  outer  membrane,  we  do  not  see  the  little 
membrane  of  the  cochlear  fenestra ;  the  whole  looks  one  uniform  red 
surface,  and  in  this  state  the  physiology  of  hearing  has  not  yet  been 
satisfactorily  explained ;  but  I  presume  that  the  waves  of  sound  im- 
pinge directly  upon  this  membrane,  and  sensations  are  thus  conveyed 
to  the  internal  ear.  That  the  membrane  vibrates  is  proved  by  experi- 
ment, and  one  use  of  it  may  be  to  allow  the  fluid  contained  within 
the  vestibule,  when  pressed  upon  by  the  base  of  the  stapes — covering, 
like  a  lid,  the  fenestra  ovalis — to  bulge  a  little  into  the  cavity  of  the 
tympanum.  But  that  this  latter  must  be  a  secondary  object  is  proved 
by  the  amount  of  hearing  possessed  by  persons  who  have  sufi"ered  from 
extensive  destruction  of  the  membrana  tympani,  or  have  even  lost 
some  of  the  ossicles. 

The  superior  opening  is,  as  its  name  implies,  oval  or  ovoid  for  the 
reception  of  the  base  of  the  stapes,  which  fits  into  it  somewhat  like  a 
stopper,  or  a  piston  of  a  cylinder,  and  is  attached  to  its  circumfe- 
rence by  a  ligamento-fibrous  membrane,  which  allows  a  double  motion 
to  the  small  bone  which  it  surrounds, — a  stopper-like  one  by  which  it 
is  forced  toAvards  the  cavity  of  the  vestibule,  with  which  this  opening 
communicates,- — and  a  lateral  or  oscillating  one  by  which  each  of  its 


ANATOMY    OF    THE    CAVITAS    TTMPANI.  301 

extremities  can  be  made  to  press  inwards  in  turn.^  The  surface  of 
the  promontory  is  grooved  for  the  ramification  of  the  tympanic 
branches  from  the  glosso-pharyngeal  nerve.  Traversing  the  superior 
wall  of  the  tympanum,  immediately  above  the  fenestra  ovalis,  is  the 
aqueduct  of  Fallopius  for  the  transmission  of  the  facial  portion  of 
the  seventh  pair  of  nerves,  which  projects  somewhat  into  the  roof  of 
the  tympanic  cavity,  and  the  relations  of  which  have  already  been  re- 
marked upon  j)age  213.  Posteriorly  and  immediately  below  this  con- 
duit of  the  facial,  we  observe  a  little  conical  eminence  called  the 
pyramid,  in  the  apex  of  which  there  is  a  depression  leading  into  an 
opening  which  gives  insertion  to  the  stapedius  muscle. 

From  the  large  sinus  in  the  roof  of  the  tympanum,  or  sometimes 
by  one  or  two  openings  in  addition,  the  mastoid  cells  communicate 
freely  with  the  cavitas  tympani,  and  it  is  of  great  importance  to  bear 
this  communication  in  mind,  when  inflammation  attacks  the  tympanum, 
which  space,  as  well  as  these  mastoid  cells,  are  separated  from  the 
cavity  of  the  cranium  by  a  thin  and  often  delicate  lamina  of  bone, 
pierced  by  several  small  apertures  for  the  transmission  of  vessels  to 
the  dura  mater,  which  adheres  intimately  to  the  superior  surface  of 
the  bone  at  this  place. 

Anteriorly  and  somewhat  inferiorly  the  whole  side  of  the  tympanal 
ca^dty,  from  the  attachment  of  the  membrana  tympani  in  front  to  the 
root  of  the  promontory  behind,  may  be  seen  the  smooth  trumpet- 
shaped  entrance  of  the  Eustachian  tube ;  and  not  as  it  is  described 
in  books,  commencing  by  a  small  aperture  ;  on  the  contrary,  it  is  the 
widest  part  of  the  body  portion  of  that  canal.  Along  its  posterior 
margin,  somewhat  above  the  middle,  a  delicate  concave  shelf  of  bone 
stands  out,  which  forms  the  floor  of  a  canal,  completed  by  fibrous 
membrane,  through  which  the  tensor  tympani  muscle  plays.  The 
length  of  the  bony  portion  of  the  Eustachian  tube  is  about  half  an 
inch,  and  of  an  irregular  elliptical  figure,  sometimes  resembling  a 
mere  slit,  and  seldom  admitting,  even  in  the  dry  bone,  anything 
larger  than  an  ordinary-sized  dessing  probe,  and  certainly  not  capable 

1  See  the  splendid  work  of  Professor  Hyrtl  of  Vienna,  upon  the  Comparative  Ana- 
tomy of  the  Ear,  "  Vergleichend-anatomische  Untersuchungen  iiber  das  innere  Gehororgan  des 
Menschen  mid  der  Saugelhiere."  See  also,  in  addition  to  the  various  vi^orks  upon  Ana- 
tomy, and  Mr.  Wharton  Jones'  Essay  in  the  CyclopEedia  of  Anatomy  and  Physiology, 
the  recently  published  paper  by  Mr.  Toynbee  "  On  the  Functions  of  the  Muscles  of  the 
Tympanum  in  the  Human  Ear,"  in  the  British  and  Foreign  Medico-Chirurgical  Review 
for  January,  1853. 


302  ANATOMY    OP    THE     CAVITAS    TYMPANI. 

of  giving  transit  to  the  great  majority  of  the  bougies  and  other  instru- 
ments recommended  by  aurists  to  be  passed  through  it  for  the  purpose 
of  clearing  it,  or  of  exploring  (?)  the  cavitas  tympani. 

The  parts  contained  within  the  tympanum  are  : — the  ossicula  au- 
ditus,  the  muscles  by  which  these  bones  are  moved  and  the  chorda 
tympani  nerve,  which  in  its  circuitous  course  traverses  the  upper  part 
of  this  cavity. 

This  chain  of  small  bones  has  three  points  of  attachment, — the 
membrana  tympani,  and  the  fenestra  ovalis,  between  which  they 
stretch,  and  the  walls  of  the  tympanum,  which  afford  them  support. 
They  consist  of  the  malleus  or  hammer,  the  incus  or  anvil,  and  the 
stapes  or  stirrup  ;  to  which  some  anatomists  have  added  a  fourth  bone, 
under  the  name  of  the  orbicular,  but  which  is  now  believed  to  be  a 
portion  of  the  incus.  All  these  bones,  when  placed  together,  form 
an  arched  chain  of  levers,  extending  across  the  upper  and  back  por- 
tion of  the  tympanal  cavity,  and  which  by  their  motions  serve  to  con- 
vey vibrations  of  sound  from  the  membrana  tympani,  to  which  they 
are  att&,ched  externally,  to  the  fenestra  ovalis,  where  the  inner  leg  of 
the  arch  is  fastened  ;  and  also  to  place  both  the  membrana  tympani 
and  the  membrane  of  the  fenestra  rotunda  in  particular  states  of  ten- 
sion or  relaxation,  whereby  they  can  be  affected  by  sounds  more  or 
less  grave  or  acute.  For  this  latter  purpose  their  mechanism  is  under 
the  control  of  muscles  probably  of  the  voluntary  class.  The  malleus 
or  hammer  consists  of  a  body  fitted  into  a  corresponding  surface  in 
the  incus  ;  a  head  rising  into  the  tympanic  sinus  above  the  attachment 
of  the  membrana  tympani ;  a  manubrium  or  handle  stretching  down 
between  the  laminae  of  the  latter  structure,  to  which  it  gives  insertion 
and  support,  as  already  explained  at  page  213  ;  a  tubercle  between 
the  body  or  neck  and  handle,  which  is  always  recognizable  through  the 
membrana  tympani ;  and  a  long  slender  process,  which,  springing  at  a 
right  angle  from  the  rest  of  the  bone,  crosses  the  tympanal  cavity 
obliquely  from  behind  forwards,  and  a  little  downwards  towards  the 
Glasserian  fissure,  where  it  is  attached  near  the  edge  of  the  tympanic 
ring.  The  incus  is  also  an  irregularly-shaped  bone,  not  inaptly  re- 
sembling a  bicuspid  tooth ;  the  crown  of  which  is  articulated  to  a  cor- 
responding surface  upon  the  malleus,  and  the  two  fangs  or  crura  are 
attached,  the  shorter  by  ligament  to  the  roof  of  the  tympanum  near 
the  orifice  of  the  mastoid  cells,  and  the  long  process,  extending  down- 
wards nearly  parallel  with  the  handle  of  the  malleus,  but  towards  the 
inner  wall  of  the  tympanum  is  articulated  with  the  head  of  the  stapes. 


ANATOMY    OF    THE    CAVITAS    TYMPANI.  808 

The  stapes  itself,  which  in  its  similitude  to  a  stirrup  is  perhaps  the 
most  exact  resemblance  which  any  portion  of  anatomy  has  yet  derived 
a  name  from,  is  set  by  its  base  into  the  opening  of  the  vestibule,  and 
thus  completes  the  connecting  links  between  the  external  and  internal 
ears.  From  the  anatomical  relations  of  this  bone,  and  its  acting 
either  with  an  intervening  membrane — the  membrana  vestibuli  of  for- 
mer anatomists — or  simply  by  ligamentous  connexions  to  the  edge  of 
the  foramen  ovalis,  as  the  principal  barrier  to  the  escape  of  the  con- 
tents of  the  vestibuli,  the  semicircular  canals,  and  even  the  cochlea, 
its  total  destruction  or  removal  must  be  attended  with  irreparable 
loss  of  hearing,  unless  the  foramen  ovalis  becomes  filled  up  with  a  new 
or  false  membrane,  and  that  the  labyrinthine  fluid  re-accumulates. 
Fortunately,  this  little  bone  is  less  frequently  lost  in  otorrhoea  than 
either  of  the  others.  The  various  articular  surfaces  between  these 
minute  bones  are  incrusted  with  cartilages,  provided  with  synovial 
membranes,  and  held  together  by  minute  ligaments.^ 

The  muscles  which  move  these  small  bones  are  the  tensor  tympani 
and  the  stapedius  ;  the  former  of  which  arises  in  the  osseo-cartilaginous 
canal  above  the  Eustachian  tube  already  described,  and,  crossing  the 
upper  portion  of  the  tympanumx,  is  attached  to  the  malleus  near  the 
junction  of  the  tubercle  and  handle,  which  bone  it  draws  inwards  and 
forwards,  and  so'  assists  to  render  the  membrane  which  it  supports, 
concave  externally ;  bu#  whether  that  structure  is  really  rendered 
more  tense  or  more  relaxed  by  this  action,  remains  for  further 
investigation.  It  would  appear  from  observing  the  mechanism  of  the 
chain  of  bones  extending;  between  the  external  and  internal  walls  of 
the  tympanum,  that  the  action  of  the  tensor  tympani  must,  by  drawing 
the  malleus  inwards,  aflFect  the  position  and  motions  of  the  stapes 
upon  or  within  the  fenestra  ovalis.  If,  as  anatomists  suppose,  the 
action  of  the  tensor  tympani  assists  indirectly  to  press  the  base  of 
the  stapes  inwards  towards  the  cavity  of  the  vestibule,  it  is  manifest 
that  it  must  affect  the  fluid  of  the  labyrinth,  and  by  its  means  press 
outwards  the  membrane  of  the  fenestra  rotunda.  But  if  the  long  leg 
of  the  incus,  through  which  the  motion  of  the  tensor  tympani   is 

'  It  is  said  that  at  birth  the  ossicles  are  as  large  as  in  the  adult.  The  stapes,  says  Mr. 
Williams,  "  weighs,  when  dried,  one  thirty-second  of  a  grain."  This  is  a  great  exaggera- 
tion. I  find  from  five  to  six  of  these  little  bones  weigh,  in  the  dry  state,  a  grain.  The 
same  author,  in  that  Treatise  for  which  the  University  of  Edinburgh  awarded  a  gold 
medal,  states  that  "  the  membrana  tympani  is  covered  with  wax,  which  is  for  the  purpose 
of  modifying  sound  "  ! ! 


304  ANATOMY    OF    THE    CAVITAS    TYMPANI. 

conveyed  to  the  top  of  the  stapes  (instead  of  pressing  point-blank 
against  that  bone  in  its  ordinary  horizontal  position,  so  as  to  bear  upon 
it  like  the  piston  rod  of  a  cylinder),  presses  it  obliquely,  and  gives  its 
base  an  oscillatory  motion,  it  is  as  likely  to  relax  the  membrane  of 
the  fenestra  rotunda  by  withdrawing  the  pressure  of  a  portion  of  the 
stapes  from  the  fenestra  ovalis.  And  the  oblique  position  at  which 
the  incus  articulates  with  the  stapes  renders  this  probable ;  so  that  it 
is  only  by  a  combined  action  of  the  tensor  tympani  and  stapedius 
muscles  that  the  base  of  the  stapes  can  be  pressed  directly  inwards 
against  the  fluid  of  the  vestibule.  The  stapedius  muscle,  which  is 
much  shorter  and  smaller  than  the  preceding,  arises  within  the 
aperture  of  the  pyramid,  and  is  inserted  into  the  head  of  the  stapes. 
By  some  it  is  supposed  to  act  as  an  antagonist  to  the  tensor  tympani ; 
and  this  opinion  receives  support  from  the  fact,  that  it  is  supplied  by 
a  branch  from  the  facial  nerve,  while  the  latter  receives  its  nervous 
supply  from  the  otic  ganglion ;  but,  says  Mr.  Wharton  Jones,  "  the 
principal  nerve  of  the  tensor  tympani  is  derived  from  the  pterygoid 
nerve  of  the  third  branch  of  the  fifth."  Its  action  is  to  draAv  the 
stapes  backwards,  and  consequently  elevate  that  portion  of  its  base 
contained  within  the  anterior  edge  of  the  fenestra  ovalis.  It  is 
remarkable,  that  both  these  muscles  have  their  origin  within  fine  bony 
canals  which,  projecting  somewhat  into  the  tympanal  cavity,  serve  to 
give  them  an  exact  and  sjoecial  direction ;  and,  as  particulary  occurs 
in  the  case  of  the  tensor  tympani,  by  means  of  pulley-like  tendons, 
slightly  to  alter  the  original  direction  of  their  course.  Both  muscles 
acting  together,  the  tensor  tympani,  by  pressing  the  anterior  edge  of 
the  base  of  the  stapes,  and  the  stapedius  its  posterior  extremity,  must 
press  it  inwards,  and  so  affect  the  fluid  of  the  labyrinth  and  the 
membrane  of  the  fenestra  rotunda. 

The  action  of  these  bones  and  muscles  is  tAvofold — when  vibrations 
of  sound  impinge  on  the  membrana  tympani  to  convey  its  minutest 
motion  across  the  tympanum,  and  communicate  such  to  the  labyrinth ; 
and  also  to  act  as  the  analogue  of  the  iris,  and  thus,  by  regulating 
the  state  of  tension  of  the  different  structures  thrown  into  vibration, 
to  control  the  amount  of  sonorous  undulations  that  pass  to  the 
labyrinth.  With  respect  to  the  problem  regarding  the  voluntary 
action  of  the  tympanic  muscles,  Mr.  Pilcher  writes :  as  they  "  are 
supplied  from  the  two  sources, — from  the  voluntary  system  by  the 
portio  dura,  and  from  the  ganglionic  by  the  chorda  tympani  and  the 
otic  ganglion, — is  it  not  probable  that  they  may  be  of  a  mixed  character, 


ANATOMY    OF    THE    MASTOID    CELLS.  305 

acting  involuntarily  when  the  acoustic  nerve  is  over-excitecl,  or  when 
the  mind  is  othermse  engaged,  and  attention  not  directed  to  the 
protection  of  the  membrane  and  of  the  ear  in  general;  and  being 
influenced  by  volition,  when  the  individual  is  desirous  to  increase  or 
to  diminish  his  mental  perceptions?"  Mr.  Toynbee,  who  has  lately 
written  an  ingenious  article  upon  the  subject  (see  Note,  page  301), 
says :  "  I  think  it  may  be  fairly  inferred,  that  the  function  of  the 
tensor  tympani  muscles  is  to  protect  the  membrana  tympani  and  the 
labyrinth  from  injury  dm'ing  loud  sounds ;  while  the  stapedius  muscle 
places  these  structm^es  in  a  position  to  be  impressed  by  the  most 
delicate  vibrations ;  and  it  would  appear  to  be  brought  into  action 
during  the  process  of  listening." 

The  Vidian  nerve,  after  leaving  the  portio  dura  near  its  exit  from 
the  aqueduct  of  Fallopius,  enters  the  tympanum,  where  it  receives  the 
name  of  chorda  tympani,  by  a  special  opening  behind  the  posterior 
margin  of  the  tympanic  groove,  and  forming  an  arch  close  to  the 
roof  of  the  cavity,  runs  to  the  canal  beside  the  fissure  of  Glasser; 
passing  in  this  com-se  between  the  handle  of  the  malleus  in  front  and 
the  long  process  of  the  incus  behind.  In  explanation  of  the  peculiar 
tortuous  course  of  this  most  remarkable  nerve,  and  its  final  association 
with  the  gustatory,  submaxillary,  and  dental  supply,  Professor  Harri- 
son says : — "  This  connexion,  also,  so  close  to  the  tympanum,  which 
contains  the  ossicula  and  musculi  auditus,  may  be  designed  to  impart 
the  twofold  properties  of  sensation  and  of  motion  to  this  apparatus, 
through  the  filaments  which  connect  the  portio  dura  subsequently  to 
the  tympanic  plexus :  thus  the  organ  of  hearing,  like  that  of  vision^ 
will  be  furnished  with  the  three  sets  of  nerves,  one  for  special  sense, 
one  for  sensation,  and  one  for  motion."  (Dublin  Dissector.)  A 
familiar  example  of  one  of  the  phenomena  resulting  from  the  course 
of  this  cm-ious  nerve  is,  that  of  having  the  teeth  "set  on  edge"  on 
hearing  the  filing  of  a  saw,  or  any  other  similar  grating  sound. 

The  mastoid  cells  are  so  irregular  both  in  size,  number,  and 
arrangement,  that  no  special  description  of  them  can  be  given ;  those 
nearest  the  tympanum,  one  or  two  in  particular,  are  the  largest; 
in  a  pathological  point  of  view,  it  is  sufficient  to  know  that  they 
communicate  freely  with  the  cavitas  tympani,  and  are  lined  by  a 
continuation  of  its  investing  membrane ;  they  also  surround  the  floor 
as  well  as  the  posterior  wall  of  the  tympanum ;  and  the  former  locality 
is  frequently  seen  covered  with  small  cells  in  the  dried  bone.  One  of 
.  the  best  methods  of  displaying  the  form  and  continuity  of  these  cells 

20 


306       ANATOMY  OF  THE  EUSTACHIAN  TUBE. 

is  by  a  cast  taken  in  type  metal,  when  they  resemble  a  bunch  of 
grapes  attached  by  the  stalk  to  the  portion  filling  the  tympanum. 
Anatomists  and  physiologists  have  not  yet  offered  an  unobjectionable 
theory  to  account  for  the  existence  of  the  mastoid  cells,  which  are 
only  developed  in  adult  life.  The  generally  received  opinion  is,  that 
they  permit  a  greater  degree  of  resonance  in  the  cavity  of  the 
tympanum  than  would  otherwise  occur.  It  has  been  advanced  that, 
by  affording  a  greater  amount  of  surface  for  the  expansion  of  the 
mucous  membrane  of  the  tympanic  cavity,  like  the  Schneiderian 
membrane  in  the  ethmoid  cells  and  frontal  sinuses,  they  thereby 
increase  the  powers  of  hearing ;  but  we  have  no  warrant  for  believing 
that  the  membrane  is  endowed  with  that  faculty.  I  am  inclined  to 
think  that,  independent  of  their  mechanical  use  in  affording  lightness 
with  stability  to  the  mastoid  process,  they  act  as  a  diverticulum  or 
reservoir  for  the  air  contained  in  the  tympanic  cavity;  and  their 
being  placed  nearly  opposite  the  entrance  of  the  Eustachian  tube 
rather  favors  the  idea.  If  there  was  not  some  such  space  in  which 
air  might  be  occasionally  compressed,  I  believe  the  membrane  would 
be  ruptured  in  forcible  expirations, — such  as  sneezing,  coughing,  or 
violently  blowing  the  nose, — as  well  as  sudden  loud  noises  acting  from 
without,  much  more  frequently  than  usually  occurs.  And  when  the 
membrane  bursts  during  the  progress  of  otitis  (which  generally  occurs 
during  a  violent  expiration),  it  must  be  remembered  that  the  mastoid 
cells  are  either  blocked  up  by  the  inflammatory  process  or  filled 
with  pus. 

The  Eustachian  tube  consists  of  an  osseous  and  a  cartilaginous 
portion ;  the  average  length  of  the  former  is  about  half  an  inch,  in 
width  it  is  about  the  eighth  of  an  inch  from  above  downwards,  and 
not  more  than  the  tenth  from  before  backwards,  or  from  side  to  side. 
This  tube  is  separated  from  the  carotid  canal  by  a  very  thin  plate  of 
bone.  The  membrano-cartilaginous  portion  is  fully  an  inch  long ;  it 
is  attached  to  the  notched  irregular  extremity  of  the  osseous  part  in 
the  petrous  portion  of  the  temporal  bone,  and  also  to  the  edge  of  the 
sphenoid.  This  is  generally  the  narrowest  part  of  the  tube,  and  from 
thence  in  its  downward  and  inward  direction  to  its  gutteral  orifice  in 
the  pharynx  it  gradually  enlarges,  but  more  particularly  at  its  lower 
extremity.  It  thus  resembles  a  straight  trumpet,  the  small  enlarge- 
ment of  the  mouth-piece  being  at  the  tympanum,  and  the  larger  bell- 
shaped  extremity  opening  behind  the  posterior  nares,  with  its  lower 
margin  a  little  below  the  floor  of  that  aperture.     Viewed  in  the 


ANATOMY    OF    THE    CAVITAS     TYMPANI.  307 

recent  state,  by  making  a  central  vertical  section  through  the  base 
of  the  skull,  mouth,  and  pharynx,  the  lower  opening  of  the  Eusta- 
chian tube  presents  an  obKquely  upright  elliptical  slit  or  fissure  about 
half  an  inch  long,  with  thick,  round,  and  slightly  prominent  lips. 
Placed  thus  behind,  and  so  much  above  the  hard  and  soft  palate,  it 
is  manifest  that  the  tonsils,  even  when  enlarged,  cannot  press  upon 
its  partially  open  mouth  without  first  coming  in  contact  with  the 
palate  plate,  and  lifting  upwards  and  backwards  the  velum,  which,  it 
is  well  known,  never  occurs.  When  the  tonsils  are  in  a  state  of 
chronic  enlargement  from  hypertrophy  of  their  follicles,  thickening  of 
their  mucous  membrane,  and  cheesy,  calcareous,  or  other  abnormal 
deposits  within  their  structure, — they  first  project  towards  one 
another,  and  consequently  encroach  upon  the  size  and  shape  of  the 
isthmus  faucium,  then  towards  the  cavity  of  the  mouth,  and  after- 
wards into  the  bag  of  the  pharynx.  I  have  never  seen  nor  heard  of 
a  preparation  showing  the  greatest  possible  degree  of  enlargement  of 
the  tonsil,  in  which  it  pressed  upon  the  trumpet-mouth  of  the  Eu- 
stachian tube.  Anatomists  will,  therefore,  find  it  as  difficult  to  be- 
lieve that  enlarged  tonsils  produce  deafness  as  practical  surgeons  to 
believe  that  their  removal  can  in  any  way  relieve  loss  of  hearing. 
Even  in  cases  of  cynanche  tonsillaris,  when  so  large  a  collection  of 
matter  forms  in  the  gland  that  sufibcation  threatens,  there  is  no  deaf- 
ness. When  deafness  coexists  with  enlarged  tonsils,  I  believe  it  is 
produced  by  the  thickening  of  the  mucous  membrane  extending  into 
the  Eustachian  tube,  or  into  the  tympanum.  The  direction  of  the 
Eustachian  tube  is  forwards,  inwards,  and  downwards,  towards  its 
fellow  on  the  opposite  side,  so  that  if  a  line  passing  through  the 
centre  of  each  was  prolonged,  it  would  cross  that  of  the  other  side  at 
an  acute  angle  about  the  middle  of  the  palate  bone.  It  is  partially 
fixed  by  the  hamular  process  and  the  levator  palati  muscle ;  and  its 
connexions  with  the  muscles  of  the  pharynx  must  always  render  it 
liable  to  alteration  in  the  acts  of  mastication,  deglutition,  coughing, 
sneezing,  or  yawning.  It  must  not  be  supposed  that  the  Eustachian 
is  a  tube  always  open,  no  more  than  the  urethra ;  although  provided 
with  cartilage,  its  sides  are,  in  the  middle  third  of  its  course  at  least, 
usually  in  contact. 

The  great  gastro-pulmonary  mucous  membrane,  passing  up  over 
the  nose  and  pharynx,  is  continued  into  the  Eustachian  tube,  at  the 
orifice  of  which  it  presents  the  same  characters  with  that  lining  the 
mouth  and  throat,  being  highly  vascular,  and  studded  with  numerous 


308  ANATOMY     OF    THE    CAVITAS    TYMPANI. 

fine  glands,  which  secrete  a  plentiful  supply  of  the  usual  fluid  poured 
out  from  that  structure  ;  and  we  can,  therefore,  understand  how  affec- 
tions of  these  membranes  may,  by  continuity  of  surface,  extend  into 
the  upper  portion  of  the  tube  and  middle  ear.  As  the  membrane 
advances  towards  the  osseous  part  of  the  tube,  where  it  becomes  peri- 
osteal and  fibro-mucous,  its  characters  change :  it  is  less  red,  presents 
fewer  follicles,  is  remarkably  fine ;  and  the  villi  on  its  surface  are 
supposed  to  possess  that  peculiar  vibratory  motion  which  Purkinjie 
and  Valentin  discovered  some  years  ago.  As  it  approaches  the 
upper  extremity  of  the  tube  it  becomes  still  more  pale  and  delicate 
until  it  enters  the  cavity  of  the  tympanum,  in  the  healthy  normal 
state  of  which  it  is  of  such  smoothness  and  tenacity  as  to  be  demon- 
strated with  difiiculty ;  yet  in  disease  or  by  exposure,  as  every  practi- 
cal aural  surgeon  knows,  it  becomes  in  succession  highly  vascular, 
villous,  thickened,  infiltrated,  pulpy,  and  even  sarcomatous,  bleeding 
freely,  secreting  mucus  largely,  sometimes  pouring  out  pus  in  an 
incredibly  short  space  of  time,  and  throwing  out  fungous  granula- 
tions, &c.  In  the  cavity  of  the  tympanum  it  spreads  over  every  sur- 
face, and  is  reflected  round  the  various  bones,  ligaments,  muscles,  and 
nerves,  and  over  the  membranes  closing  the  external  auditory  and 
cochlear  apertures ;  and  also  extends  into  the  large  series  of  mastoid 
cells ;  so  that,  like  the  superficies  of  the  peritoneum,  it  presents,  on  a 
careful  consideration  and  examination  of  the  parts,  a  much  more  ex- 
tensive surface  than  would,  at  a  superficial  glance,  appear.  In  ana- 
tomical characters,  as  well  as  in  pathological  phenomena,  the  lining 
of  the  lachrymal  passage  has  many  points  of  analogy  with  the  tym- 
pano-Bustachian  mucous  membrane,  which  those  familiar  with  the 
structure,  relations,  and  diseases  of  both  will  upon  reflection  perceive, 
and  may  in  treatment  follow  out.  In  the  normal  state  the  lining  of 
the  tympanic  cavity  presents  a  smooth,  dry,  but  polished  surface,  of 
a  grayish-white  color,  somewhat  like  the  external  aspect  of  the  mem- 
brana  tympani,  but  frequently  presenting,  as  a  post  mortem  appear- 
ance, a  slightly  pinkish  hue :  being  in  a  healthy  state  transparent, 
its  color  must  be  that  of  the  bone  beneath.  Like  all  mucous  surfaces, 
it  exhales  moisture,  but  the  quantity  must  be  so  slight,  and  the  fluid 
so  very  fine,  that  it  finds  a  ready  outlet  through  the  Eustachian  tube. 
In  the  foetus  the  membrane  is  highly  vascular  and  secretes  mucus, 
which  is  often  found  filling  up  the  tympanum.  Perhaps  the  variety 
in  .the  period  of  audition  may  depend  upon  the  more  or  less  rapid 
absorption  or  excretion  through  the  Eustachian  tube  of  this  mucus ; 


AXATOMY    OF     THE     CAVITAS     TTMPANI.  309 

while  its  presence  in  the  very  early  periods  of  life  may  be  useful  in 
protecting  the  internal  ear  and  auditory  nerve  from  the  injurious 
influences  of  sound  in  their  then  delicate  condition, — in  the  same 
manner  as  the  closed  eyelids  of  cats  and  some  other  animals  for  the 
first  eight  or  nine  days  after  bii'th  protect  them  from  the  injurious 
efi"ects  of  light. 

I  have  thought  that  the  increase  of  the  lower  jaw  at  the  period  of ' 
the  first  dentition  (the  usual  time  when  infants  are  first  attracted  by 
sounds),  by  its  condyle  pressing  on  the  cavity  which  forms  the  lower 
boundary  or  floor  of  the  tympanum,  serving  to  enlarge  it  by  pressing 
upwards  and  outwards  of  the  tympanic  ring,  and  also  by  the  develop- 
ment of  the  dental  organs  not  only  altering  the  position  of  the  max- 
illa itself,  but  calling  into  action  a  hitherto  but  little  employed  set  of 
muscles, — might  so  change  the  position  and  calibre  of  the  inferior 
portion  of  the  Eustachian  tube  as  to  afibrd  a  ready  outlet  for  the 
contents  of  the  tympanum.  In  support  of  this  view,  I  may  mention 
that,  in  many  cases  of  partial  deafness,  as  well  as  defective  speech, 
and  in  some  instances  of  stammering,  there  is  not  only  a  great  delay 
in  the  usual  hearing  period  at  infancy,  but  a  very  peculiar  formation 
of  mouth.  In  many  of  those  cases  which  I  have  examined,  the  palate 
plate  was  remarkably  high  and  narrow  behind  the  incisors,  which,  as 
well  as  several  of  the  other  teeth,  were  u-regular,  and  had  been  slowly 
and  with  difficulty  developed.^ 

This  lining  membrane  of  the  middle  ear  is  highly  endowed  with 
nerves  from  the  fifth,  the  portio  dm-a  of  the  seventh,  and  the  nervus 
anastomosis  of  Jacobson, — known  as  the  tympanic  plexus,  formed 
between  the  Vidian,  glosso-pharyngeal,  twigs  from  the  otic  ganglion 
of  Arnold,  and  the  sympathetic, — which  lies,  as  already  stated,  on 
the  inner  wall  of  the  tympanum.  In  a  healthy  state  I  do  not  think 
this  mucous  lining  is  so  exquisitely  sensitive  as  the  membrana  tym- 
pani.  The  cavitas  tympani  is  as  largely  supplied  with  blood-vessels 
as  the  membrana  tympani,  already  described  and  figured  at  page 
215,  and  derived  from  nearly  the  same  som-ces, — the  stylo-mastoid 
from  the  posterior  auricular, 'which  enters  through  the  hiatus  of  Fallo- 
pius,  and  branches  from  the  temporal,  internal  maxillary,  middle 
meningeal,  and  the  internal  carotid.  The  pathological  conditions 
which  the  cavitas  tympani  presents  in  the  dead  subject  are  related 
at  page  117 ;  and  the  abnormal  -states  of  that  space  during  life,  and 

'  With  respect  to  the  period  of  audition,  see  the  Chapter  on  the  Internal  Ear,  and'also 
the  Appendix  on  Deaf-dumbness. 


310  INJUEIES    OF    THE    TYMPANUM. 

also  the  conditions  of  the  middle  ear  and  Eustachian  tube,  are  exhi- 
bited in  the  Registry  of  Cases. 

MALFORMATIONS    OF   THE    CAVITAS   TYMPANI   AND   EUSTACHIAN   TUBE. 

As  modern  anatomists  have  paid  particular  attention  to  the  primi- 
tive formation  of  the  cavity  of  the  tympanum,  many  of  the  congenital 
malformations  which  it  presents  are  explained  upon  the  principle  of 
arrest  of  development.  As  already  stated,  the  cavity  of  the  tym- 
panum may  be  absent,  its  site  consisting  of  solid  bone ;  it  has  also 
been  found  much  smaller  than  natural,  showing  a  persistence  of  the 
characters  observed  during  foetal  life.  Its  fenestras  are  at  times  but 
rudimentary,  closed  by  bony  matter,  or  altogether  absent ;  and  the 
cavity  has  been  found  filled  with  morbid  deposits.  The  ossicula  are 
liable  to  great  variety, — they  may  be  altogether  or  partially  deficient ; 
when  the  stapes  is  wanting,  ossified  to  the  edge  of  the  fenestra  ovalis, 
or  disconnected  with  the  incus,  considerable  impairment  of  hearing 
must  follow.  But,  in  the  great  majority  of  instances  in  which  malfor- 
mations to  any  amount  existed  in  the  cavitas  tympani  or  its  contents, 
the  subjects  of  such  were  either  infants  whose  state  of  audition  could 
not  be  learned,  or  persons  congenitally  deaf  and  dumb.  I  have 
already  spoken  of  the  irregularity  which  the  malleus,  as  seen  through 
the  membrana  tympani  occasionally  presents  in  some  deaf  mutes. 
The  Eustachian  tube  has  been  found  altogether  wanting  or  partially 
impervious. 

INJURIES    OF   THE   TYMPANUM. 

Considerable  hemorrhage  takes  place  from  the  ears,  and  pours  out 
of  the  external  meatus,  not  merely  in  cases  of  violent  mechanical 
injury,  and  from  the  vicinity  of  loud  and  unexpected  noises,  as  already 
explained  at  page  220,  but  in  cases  of  sudden  death  from  strangula- 
tion and  some  other  forms  of  asphyxia.  Bleeding  from  the  ears,  as 
well  as  the  nose,  mouth,  eyes,  and  genitals  usually  occurs  in  hanging 
as  a  public  execution,  but  not  always  when  it  is  suicidal.  In  such 
cases  it  is  believed  that  the  hemorrhages  are  the  result  of  congestion"; 
and  if  this  be  true,  that  from  the  ears  must  come  from  the  meatus  or 
from  the  tympanal  cavity  through  a  ruptured  membrana  tympani. 
Littre  found  the  membrana  tympani  ruptured  in  a  case  of  strangula- 
tion ;  but,  as  I  already  stated  in  two  previous  portions  of  this  work, 
the.  source  of  the  hemorrhage,  and  the  cases  in  which  it  occurs,  either 
as  a  constant  or  variable  symptom,  have  not  yet  been  fully  investi- 


INJURIES    01*    THE    TYMPANUM.  311 

gated.  A  case  has  just  occurred  in  this  city,  for  the  particulars  of 
which,  as  well  as  the  use  of  the  preparation  from  which  the  accom- 
panying illustration  was  made,  I  am  much  indebted  to  Professor 
Geoghegan.  A  female,  aged  40,  strangled  herself,  by  twisting  a 
ribbon  round  her  neck,  during  the  present  month, — February,  1853. 
She  was  discovered  by  the  police  next  morning,  and  Professor  Geog- 
hegan made  a  post  mortem  examination  of  the  body  a  few  hours 
afterwards.  The  face  and  lips  were  of  a  dusky  red,  but  unswoUen, 
and  blood  poured  out  of  the  left  meatus.  It  is  sufficient  for  me  to 
state  the  particulars  of  the  examination  as  regards  the  ear,  which  was 
carefillly  removed.  A  section  having  been  made  through  the  internal 
ear,  it  exposed  the  cavity  of  the  tympanum,  which  was  found  to  con- 
tain a  very  little  bright  fluid  blood,  a  trace  of  which  had  passed  for 
some  distance  into  the  Eustachian  tube  ;  the  mucous  membrane  of  the 
ca^dty  of  the  tympanum  did  not  seem  to  be  congested,  but  was  par- 
tially stained  with  the  blood  which  lay  in  it.  The  membrana  tym- 
pani  presented  a  mottled  red  and  semitransparent  appearance,  the 
foraier  being  the  result  of  blood  extravasated  upon  its  sm-face  and 
between  its  laminae.  Towards  its  posterior  attachment,  a  little  behind 
and  below  the  tubercle  of  the  malleus,  the  membrane  was  red,  and 
presented  the  triangular  aperture  shown  in  the  accompanying  repre- 
sentation ;  the  anterior  inferior  angle  of  the  aperture  is  nearly  on  a 
level  with  the  end  of  the  manubrium,  and  the  posterior  margin  of  the 
triangle  corresponds  with  the  insertion  of  the  membrane  into  the  tym- 
panic ring ;  but  the  rent  does  not  run  quite  into  it.  Owing  to  the 
rupture  of  the  radiating  fibres, — which  are  natm^ally  j-jg.  21. 

feeble  at  this  point, — the  handle  of  the  malleus  is       ^r-^iw^~-:-f-\ 
drawn    somewhat   forwards    and    upwards    from   its      M|('!^^^^to 
natural   position.     In   the   preparation,   the    chorda      lli^^^^i> 
tympani  nerve  is  plainly  seen  upon  the  inside  bound-       ^I'l^^^-^ 
ing  the  upper  angle  of  the  aperture,  which  rather 
curves  inwards  towards  the  malleus,  leaving  a  small  portion  of  mem- 
brane above  and  behind  it,  while  the  posterior  angle  of  the  rent  runs 
nearly  into  the  tympanic  ring.     The  tensor  tympani  muscle  pre- 
serves its  attachment  to  the  malleus.     The  inner  wall  of  the  tympanic 
cavity  having  been,  in  great  part,  removed,  as  well  as  the  other 
ossicula,  I  am  unable  to  state  what  the  condition  of  these  parts  was ; 
but  the  section  of  the  labyrinth  does  not  exhibit  any  vascularity  or 
extravasation,  and  all  that  portion  of  the  mucous  lining  of  the  tym- 
panic opening  of  the  Eustachian  tube,  and  as  much  of  the  cavitas 
tympani  as  remains,  present  no  congestion  or  extravasation. 


312  INJURIES    OF     THE    TYMPANUM. 

From  an  examination  of  this  unique  and  most  valuable  specimen, 
two  questions  arise, — how  did  the  rupture  occur,  and  from  whence 
did  the  hemorrhage  come  ?  Bj  reference  to  page  144,  as  well  as  an 
examination  of  the  Registry,  given  in  Chapter  III.,  it  will  be  seen 
that  the  aperture  in  the  membrane  has  taken  place  in  the  second 
most  usual  locality, — viz.,  at  the  posterior  margin  of  its  attachment, 
behind  the  malleus,  and  immediately  below  and  in  front  of  the  open- 
ing of  the  mastoid  cells, — where  a  stream  of  air,  if  forcibly  injected 
through  the  Eustachian  tube,  would  chiefly  impinge,  particularly  if 
the  mastoid  cells  were  already  filled.  That  this  jet  of  air  would, 
when  the  membrane  is  in  a  high  state  of  tension,  produce  the  rup- 
ture, I  have  no  doubt ;  but  how  caused  during  the  death-struggle  in 
strangulation,  and  with  the  mouth  and  nose  open,  I  cannot  explain. 
It  is  remarkable,  however,  that  in  this  case  the  rent  occurs  in  the 
precise  locality  where  I  described  a  cicatrix  in  the  case  of  an  artillery- 
man who  had  had  hemorrhage  from  the  ear.  (See  page  220.)  With 
regard  to  the  source  of  the  hemorrhage,  I  am  inclined  to  suppose  that 
it  came"  from  the  large  branches  of  the  stylo-mastoid  artery  whichi  de- 
scend along  the  handle  of  the  malleus  through  the  exact  space 
traversed  by  the  rent,  as  shown  in  the  illustration  at  page  215. 
This  being  the  case,  we  may  suppose  that  the  rupture  was  the  original 
cause,  and  the  hemorrhage  a  secondary  consequence.  The  only  two 
cases  on  record  in  which  there  has  been  a  careful  examination  of  the 
parts,  is  that  by  Littre  and  the  foregoing.^ 

Bleeding  occurs  from  the  ears  occasionally  during  violent  parox- 
ysms of  hooping-cough, — a  fact  corroborative  of  the  belief,  that  the 
source  of  the  hemorrhage  is  from  a  ruptured  tympanal  membrane. 
I  believe  sailors  do  not  suffer  from  cannon-firing  like  artillery-men ; 
this  may  arise  from  the  floating  substance  on  which  they  stand,  and 
also  from  the  muzzle  of  the  gun  being  separated  from  them  by  the 
side  of  the  ship. 

Whenever  the  membrana  tympani  is  pierced  or  ruptured  by  external 
violence,  the  cavity  of  the  tympanum  must  be  more  or  less  injured, 
and  the  extent  of  mischief  will  much  depend  upon  the  nature  of  the 
penetrating  instrument  or  foreign  substance  introduced;  yet  the 
results  are  not  always  what  might  be  expected  from  the  nature  of  the 

'  On  the  subject  of  hemorrhage  from  the  ears,  as  a  sign  of  certain  forms  of  death,  such 
as  the  foregoing  instance,  I  would  also  refer  my  readers  to  the  able  tract,  by  Professor 
Geoghegan,  "  An  Examination  of  the  Medical  Facts  in  the  Case  of  the  Queen  v.  W.  B. 
Kirwan."     Dublin.     Fannin  &  Co.     1853. 


INJURIES    OF    THE    TYMPANUM.  313 

injury,  as  a  piece  of  slate-pencil  may  be  driven  into  the  tympanum,  and 
inflammation  and  suppuration  alone  follow ;  whereas,  a  needle  passing 
beyond  the  membrana  tympani  has  caused  death ;  and  an  irritating 
foreign  substance  is  said  to  have  induced  epilepsy.  Dr.  Maclagan 
has  recorded  "the  history  of  a  case  of  epilepsy  and  deafness  depend- 
ing on  the  presence  of  a  foreign  body  in  the  ear.  The  patient,  when 
a  boy  about  five  years  of  age,  had  introduced  into  his  ear  what  was 
supposed  to  be  the  seed  of  a  sycamore.  Unsuccessful  attempts  were 
made  at  the  time  to  extract  it.  It  remained  in  the  ear  four  years 
without  giving  rise  to  any  uneasiness,  at  which  period  the  patient, 
then  nearly  ten  years  old,  was  seized  with  epilepsy  of  a  marked 
character.  Deafness,  which  had  hitherto  been  slight,  increased,  and 
the  epilepsy  and  deafness  continued  in  an  aggravated  form  for  six 
years  more,  or  ten  years  from  the  introduction  of  the  foreign  body. 
It  was  at  this  period  that  Dr.  Maclagan  was  consulted  for  the  deaf- 
ness ;  and  he  succeeded  in  removing  from  the  ear  the  seed,  surrounded 
by  a  nodule  of  wax  sufficiently  large  to  fill  up  the  whole  meatus. 
Under  the  ordinary  treatment  the  deafness  declined ;  and,  since  that 
period  (then  twenty  years),  he  had  no  return  of  the  epilepsy."  Such 
is  the  record  of  this  remarkable  case,  as  communicated  to  the  Edin-. 
burgh  Medico-Ohirurgical  Society,  and  published  in  the  Monthly 
Journal  for  February,  1841.  Giving  the  author  full  credit  for  his 
belief  in  the  case,  I  must  confess  that  I  am  inclined  to  bring  in  the 
Scotch  verdict  of  "non  proven,"  so  far  as  the  seed  is  concerned. 
The  state  of  the  ear,  either  before  or  after  the  removal  of  the  foreign 
body,  has  not  been  recorded;  nor  whether  the  seed  ruptured  the 
membrana  tympani,  or  caused  any  disorganization  of  the  parts; 
neither  was  the  cause  of  the  deafness  explained  in  any  way.  If  the 
introduction  of  a  foreign  body  into  the  meatus  produces  epilepsy,  I 
believe  it  must  be  by  irritating  or  pressing  upon  that  highly  sensitive 
portion  of  the  meatus,  to  which  I  have  already  referred  at  pp.  86  and 
190,  and  the  slightest  touch  of  which  will,  in  some  persons,  induce 
violent  spasmodic  coughing,  evidently  from  irritation  of  the  larynx. 
Now,  according  to  the  recent  discoveries  of  Dr.  Marshall  Hall,  the 
immediate  cause  of  epilepsy  is,  in  many  cases,  spasm  of  the  glottis ; 
and  I  think  it  possible  that  such  may  have  occurred  in  the  instance 
just  referred  to.^     Those  observations  which  I  made  at  page  180,  upon 

'  I  ana  much  indebted  to  Dr.  Douglas  Maclagan  for  having,  in  addition  to  the  above 
printed  statement,  placed  his  father's  original  MS.  of  the  case  at  my  disposal. 


314  INJURIES    OF    THE    TYMPANUM. 

the  removal  of  foreign  bodies  from  the  meatus,  are  equally  applicable 
to  the  present  subject;  and  still  greater  caution  should  be  observed 
with  respect  to  the  method  of  exploration,  and  the  endeavors  made 
to  extract  foreign  substances  without  having  such  brought  fairly  into 
view.  Cases  have  been  recorded,  both  at  home  and  abroad,  in  which 
violent  efforts  made  by  surgeons  to  remove  extraneous  bodies,  said  to 
have  been  introduced  into  the  tympanum,  have  proved  fatal.  Nitric 
acid  poured  into  the  ear  has  caused  death,^  apparently  from  inflam- 
mation extending  to  the  brain  and  its  membranes  through  the  meatus 
internus. 

Independently  of  all  these  injuries  contingent  upon  violence  applied 
directly  to  the  ear,  mischief  of  a  much  more  serious  nature  may  result 
from  the  fracture  of  the  base  of  the  skull,  or  fissure  passing  through 
the  petrous  portion  of  the  temporal  bone,  and,  consequently,  the 
middle  and  internal  ear.  In  such  a  case,  hemorrhage  from  the  ear  is 
one  of  the  earliest  symptoms ;  yet,  of  itself,  it  is  not  a  proof  of 
fracture,  as  it  may  arise  from  concussion,  but  it  is  presumptive 
evidence  of  the  former.  I  have  generally  remarked  the  blood 
particularly  thin  and  of  a  highly  florid  color  in  these  cases. 
Subsequently,  in  cases  of  fracture,  a  clear  or  pale  straw-colored 
fluid  flows  out  of  the  ear  in  immense  quantities,  so  as  to  saturate  the 
bed  on  which  the  patient  lies.  My  esteemed  preceptor,  the  late 
Abraham  Colles,  who  was  justly  considered  an  authority  upon  the 
subject  of  injuries  of  the  head,  and  who,  in  the  early  period  of  his 
practice,  enjoyed  far  more  extensive  opportunities  for  studying  these 
affections  than  will,  I  am  happy  to  say,  ever  be  again  afforded  in  this 
country,^  entertained  the  opinion,  and  taught  it  in  his  lectures,  that, 

'  See  a  case  related  by  Dr.  Morrison,  of  Newry,  in  the  Dublin  Journal  of  Medical 
Science  for  March,  1836. 

2  The  amount  of  injuries  of  the  head  received  into  the  Dublin  hospitals  sixty  or  seventy 
years  ago  was  quite  incredible ;  as,  independent  of  the  ordinary  accidents  which  must 
occur  in  a  large  city,  two  special  causes,  neither  of  which  now  exist,  then  conduced  to 
swell  their  numbers.  Those  who  have  read  Dease's  book  upon  Injuries  of  the  Head 
cannot  fail  to  have  been  struck  with  the  circumstance  that,  in  the  cases  of  most  of  the 
males  recorded,  the  injury  inflicted  was,  "hit  with  a  hanger,"  a  short,  heavy  sword 
which  the  Dublin  police  and  sevei-al  of  the  tradespeople  of  that  period  carried,  and 
which  they  appear  to  have  used  very  freely.  In  the  case  of  females,  the  violence  was 
frequently  caused  by  having  fallen  out  of  a  window  in  the  endeavor  to  reach  the  end  of 
a  stick  which  projected  therefrom,  like  a  bowsprit,  with  lines  on  each  side,  for  the  pur- 
pose of  drying  clothes.  This  contrivance  may  still  be  seen  in  some  of  the  lanes  and 
back  streets  of  the  Liberty.  My  father,  who  had  been  a  pupil  of  Dease,  and  who  had 
large  opportunities  of  treating  fractures  of  the  cranium  during  the  days  of  faction  fights 
in  Ireland,  used  to  remark,  that  blood  flowing  from  the  ears,  though  a  bad  was  not  a 
fatal  symptom,  but  the  "  welling  up"  of  serum  or  clear  fluid  was  always  fatal. 


INJURIES    OF    THE    TYMPANUM.  315 

when  tlie  patient  lay  upon  the  unaffected  side,  this  serous  fluid  merely 
"welled  up  into  the  meatus,"  but  never  overflowed  that  cavity. 
Considerable  discussion  has  arisen  as  to  the  cause  and  source  of  this 
fluid.  By  some  it  has  been  supposed,  that  it  was  the  serosity  of  the 
efi"used  blood  pressed  through  a  fissure  in  the  bone ;  by  others,  that  it 
came  from  the  cavity  of  the  cranium,  and  particularly  the  bag  of  the 
arachnoid ;  while  many  have  held,  that  this  flux  is  the  liquor  Cotunnii. 
The  subject  was  ably  treated  in  the  Archives  Gfenerales  a  few  years 
ago  by  Messrs.  Chaissaignac  and  Robert,^  the  latter  of  whom  gives 
the  following  explanation  of  this  occurrence  : — "  The  dura  mater 
becomes  very  thin  where  it  lines  the  internal  auditory  canal,  which  it 
does  closely,  and  is  continued  in  the  form  of  a  sheath,  over  the  facial 
and  the  two  branches  of  the  auditory  nerves,  as  they  leave  the 
cranium.  The  arachnoid  accompanies  the  dura  mater  to  the  bottom 
of  the  internal  auditory  canal,  and  is  then  reflected  upon  the  nerves 
of  the  seventh  pair  without  adhering  to  them,  as  at  the  base  of  the 
brain  itself.  But  the  seventh  pair  does  not  nearly  fill  the  canal,  the 
space  comprised  between  them  and  its  walls  is  filled  with  cerebro-spinal 
fluid,  which  is  known  to  be  very  abundant  at  the  inferior  and  middle 
portions  of  the  brain.  It  is  evident,  then,  that,  if  the  dura  mater  and 
the  two  contiguous  folds  of  the  arachnoid  are  ruptured  at  the  base  of 
the  internal  auditory  canal,  the  cerebro-spinal  fluid  on  the  outside  of 
the  arachnoid,  between  it  and  the  nerves,  must  escape  freely  by  this 
rupture.  We  may  conceive  even  that  a  rupture  of  the  dura  mater 
alone  would  be  sufficient  for  the  same  effect,  if  this  took  place  at  the 
very  bottom  of  the  canal,  at  the  point  where  the  arachnoid  abandons 
the  surface  of  the  dura  mater  to  fold  upon  itself,  and  form  the  double 
serous  sheath  placed  round  the  seventh  pair,  and  the  cerebro-spinal 
fluid  immediately  surrounding  this.  Once  finding  its  way  through  the 
cerebral  membranes,  the  liquid  would  easily  get  beyond  the  fine  osseous 
plate  which  separates  the,  bottom  of  the  internal  auditory  canal  from 
the  vestibule,  if  this  plate  is  fractured  ;  from  thence  it  would  traverse 
the  labyrinth,  and  reach  the  cavity  of  the  tympanum,  either  through 
the  fissure  of  the  petrous  portion,  or  through  the  fenestrum  ovale 
itself,  which  is  found  open  and  free,  in  consequence  of  the  displacement 
which  the  stapes  has  undergone.  Lastly,  from  the  cavity  of  the 
middle  ear  the  liquid  would  flow  freely  outwards  by  the  external 

'  See  numbers  for  November  and  December,  1845,  with  a  careful  resmne  of  the  opi- 
nions of  these  gentlemen  in  Ranking's  Half-yearly  Abstract,  vols.  ii.  and  iii.,  from  which 
latter  work  the  foregoing  extract  is  taken. 


316  ACUTE    OTITIS. 

auditory  canal,  through  a  rupture  which  always  occurs  in  this  case  in 
the  tympanum." 

It  is  said  that  hearing  has  been  preserved  on  the  affected  side  in 
some  of  these  accidents,  even  after  the  stapes  has  been  separated 
from  the  fenestra  ovalis,  and  the  fracture  had  passed  through  the 
walls  of  the  labyrinth;  but  I  think  this  assertion  requires  further 
proof.  Notwithstanding  the  invariably  fatal  character  of  the  fore- 
going symptom,  a  case  has  been  related  in  which  a  portion  of  brain 
is  said  to  have  escaped  through  the  ear,  and  the  patient  recovered. 
In  severe  dysuria,  urine  has  been  discharged  from  the  ears.  Hemor- 
rhage may  occur  from  the  ear  as  the  result  of  ulceration ;  and  the 
carotid  has  been  tied  to  arrest  profuse  bleeding  from  the  ear,  for 
which  see  the  section  on  Otitis  from  scarlatina,  page  325. 

INFLAMMATIONS    OP   THE   TYMPANUM. — ACUTE    OTITIS. 

The  inflammatory  affections  of  the  middle  ear  are  so  well  characte- 
rized in  those  of  the  membrana  tympani,  with  which  they  are  gene- 
rally associated, — their  symptoms  have  been  so  fully  entered  into, — 
and  their  treatment  discussed  at  such  length  in  the  preceding  portions 
of  this  work,  that  it  is  only  necessary  briefly  to  enumerate  their  diffe- 
rent forms,  to  specify  their  peculiar  symptoms  and  results,  and  to 
describe  the  best  mode  of  treatment. 

Acute  otitis,  or  inflammation  of  the  lining  membrane  of  the  cavitas 
tympani,  is  one  of  the  most  painful  affections  which  can  be  suffered ; 
and  it  is  also  at  times  one  of  the  most  fatal.  It  may  occur  at  all 
periods  of  life,  but  is  generally  a  disease  of  youth  and  middle  age. 
It  is  usually  induced  by  cold,  or  any  of  those  exciting  causes  detailed 
under  the  head  of  severe  myringitis, — like  which  disease,  a  sudden 
accession  of  pain  in  the  middle  or  towards  the  end  of  the  night  is 
often  the  first  warning  which  the  patient  receives.  In  many  of  those 
violent  fits  of  screeching  (occasionally  attended  with  convulsions)  with 
which  children  sometimes  awake  out  of  sleep,  the  true  cause  is  otitis. 
The  pain  is  described  as  of  the  most  excruciating  character,  and 
likened  "to  that  of  a  sword  piercing  through  the  ear  into  the  brain;" 
and,  although  this  extreme  suffering  intermits,  it  is  only  to  be  re- 
placed by  a  dull,  aching,  and  incessant  throbbing  in  the  ear,  and  pain 
and  soreness  often  extending  over  the  whole  side  of  the  head  and 
down  along  the  neck.  The  feeling  usually  complained  of  in  these 
quiescent  moments  is  that  of  a  "bursting  in  the  ear."     There  is  oc- 


ACUTE    OTITIS.  317 

casionally  at  the  very  commencement  over-acute  hearing ;  but,  in  the 
progress  of  the  disease,  when  mucus  has  accumulated  in  the  cavity  of 
the  tympanum,  audition  is  always  impaired,  and  in  a  short  time  total 
deafness  ensues.  Pressure  upon  the  palate  opposite  the  guttural  end 
of  the  Eustachian  tube,  or  coughing,  sneezing,  blowing  the  nose, 
mastication,  and  even  deglutition,  increases  the  pain.  There  is  also 
tinnitus  present,  which  is  generally  of  a  low,  humming  character,  but 
is  sometimes  compared  to  a  "loud  hammering."  The  physical  signs 
are,  a  brownish-red  color  of  the  membrana  tympani,  which  is  some- 
times bulged  into  the  meatus ;  but  the  vascularity  is  seldom  so  florid 
or  well  marked  as  in  myringitis ;  if  the  meatus  has  been  engaged, 
the  external  surface  of  the  membrane  is  often  whitish,  presents  a 
macerated  look,  and  its  epithelium  appears  to  be  peeling  off.  The 
patient  cannot  inflate  the  tympanum, — either  owing  to  obstruction 
from  inflammation  extending  through  the  Eustachian  tube,  or  from 
the  cavitas  tympanum  being  filled  with  extraneous  matter ;  and  the 
endeavor  to  do  so  increases  the  pain  and  sensation  of  bursting  in  the 
ear.  In  most  cases  of  severe  otitis,  the  external  auditory  conduit  is 
a.lso  engaged,  and  the  membrane  of  this  passage  is  swollen  and  thick- 
ened, so  as  to  intercept  our  view  of  the  membrana  tympani,  and  the 
auricle  itself  frequently  participates  in  the  inflammatory  action,  and 
becomes  swollen,  oedematous,  and  of  a  livid  color.  The  mastoid  pro- 
cess in  the  later  stages  of  the  disease  (after  it  has  continued  some 
days)  is  generally  tender  to  the  touch,  and  its  integument  red  and 
swollen.  In  such .  cases  it  should  be  carefully  examined  daily,  ac- 
cording to  the  method  recommended  at  page  67. 

Facial  paralysis,  from  extension  of  the  inflammation  to  the  bony 
canal  in  which  the  portio  dura  nerve  passes  round  the  tympanum, 
sometimes  attends  otitis,  to  which  symptom,  as  a  special  affection,  a 
section  is  devoted  at  page  330.  The  mucous  membrane  of  the  throat 
is  often  of  a  dusky  red,  and  sometimes  the  submucous  tissue  infiltrated 
and  swollen ;  and,  should  the  attack  have  originated  in  exposure  to 
cold,  it  is  often  attended  with  increased  mucous  discharge  from  the 
nose,  a  stuffing  in  the  frontal  sinus,  some  suffusion  of  the  conjunctiva, 
and  also  slight  lachrymation. 

In  addition  to  these  local  symptoms,  the  patient  labors  under  con- 
siderable fever ;  the  tongue  is  white,  dry,  and  often  furred ;  the  pulse 
quick  and  hard  ;  the  skin  dry,  the  bowels  constipated,  the  urine  scanty 
and  high-colored ;  but  there  is  not  much  thirst.  There  is  extreme 
restlessness,  and  the  countenance  is  always  anxious,  and  highly  indi- 


318  ACUTEOTITIS. 

cative  of  the  agony  experienced.  Intolerance  of  light  is  a  frequent 
attendant,  and  delirium  not  an  uncommon  occurrence ;  and  in  aggra- 
vated cases,  when  the  disease  spreads  to  the  internal  ear  and  the  con- 
tents of  the  cranium,  there  is  generally  a  low  moaning  present,  and 
not  unfrequently  a  tossing  of  the  head  from  side  to  side.  When  the 
head  becomes  engaged,  the  patient  is  often  unwilling  to  answer  ques- 
tions, or  to  be  disturbed  in  any  way ;  is  occasionally  unconscious  of 
surrounding  objects ;  and  does  not  at  times  even  recognise  his  friends. 
I  have  sometimes  seen  partial  coma  present,  from  which,  however,  the 
patient  could  easily  be  roused ;  and  convulsions  occasionally  occur, 
particularly  in  young  subjects.  In  this  stage  it  is  often  difficult  for 
the  practitioner  in  attendance  to  diagnose  with  accuracy  the  precise 
nature  of  the  aiBFection,  or  to  say  how  much  of  it  is  purely  local,  and 
how  much  dependent  upon  cerebral  irritation,  or  extension  of  the 
inflammation  to  the  brain  or  its  membranes.  The  cases  detailed  at 
pp.  234  and  242  are  good  examples  of  this  form  of  disease,  as  well 
as  its  appropriate  treatment.  It  must  be  borne  in  mind,  that  inflam- 
mations in  the  immediate  neighborhood  of  the  brain  often  give  rise 
to  symptoms  of  a  peculiar  character,  of  which  abscess  in  the  orbit  is 
an  instance  well  known  to  surgeons. 

The  immediate  terminations  of  the  disease  are  threefold :  first  by 
resolution,  in  which  the  pain  gradually  lessens,  the  swelling  subsides, 
and  the  hearing  is  in  time  restored,  although  the  tinnitus,  then  gene- 
rally of  a  buzzing  character,  usually  remains  for  a  long  time  after. 
In  this  case  the  inflammation  either  never  proceeded  to  suppuration, 
or,  if  muco-purulent  matter  had  accumulated  within  the  tympanic 
cavity,  it  was  absorbed,  or  it  found  a  gradual  exit  through  the  Eusta- 
chian tube,  leaving  the  lining  of  the  middle  ear  thickened,  and  its 
functions  consequently  impaired. 

In  the  second  termination  of  the  disease,  the  pent-up  matter  having 
burst  through  the  membrana  tympani  is  discharged  externally,  and 
relief  is  almost  immediately  experienced  :  thus  showing,  that  the  pain 
chiefly  depended  upon  the  unyielding  nature  of  the  structures  boimd- 
ing  the  space  within  which  it  was  contained.  The  rupture  generally 
occurs  either  opposite  the  opening  of  the  Eustachian  tube  in  the  an- 
terior vibrating  portion  of  the  membrane,  or  immediately  adjoining 
its  posterior  attachment,  behind  and  below  the  mastoid  cells,  as  I 
have  already  explained  at  page  144.  With  the  free  communication 
which  the  largest  of  these  cells  has  with  the  tympanic  cavity,  and 
the  continuity  of  structure  of  their  lining  membrane  with  that  origi- 


ACUTE    OTITIS.  319 

nally  engaged  in  the  tympanum,  it  could  scarcely  be  expected  that  a 
diffused  inflammation,  possibly  of  an  erysipelatous  character,  extend- 
ing over  the  mucous  surface  of  the  tympanum,  would  stop  short  at 
the  mastoid  cells,  even  if  we  did  not  possess  facts,  derived  from  mor- 
bid anatomy,  to  establish  the  contrary  opinion.  The  very  large 
quantity  of  purulent  matter  which  escapes  through  the  external 
meatus  when  the  outer  septum  gives  way,  or,  as  the  patient  generally 
expresses  it,  "something  bursts  in  the  ear,"  and  which  amounts  to 
two  or  three  drachms  at  the  moment,  must  have  struck  every  one 
conversant  with  aural  affections.  Where  does  this  come  from,  as  it 
is  much  more  than  the  tympanic  cavity  could  have  contained  ?  I 
believe  from  the  extensive  surface  of  the  mastoid  cells.  In  this  state 
the  case  becomes  one  of  internal  otorrhosa,  the  most  frequent  termi- 
nation of  acute  otitis. 

The  third  termination  is  always  dangerous,  and  often  fatal,  and 
should  make  the  surgeon  be  cautious  and  guarded  in  his  prognosis. 
The  inflammatory  process,  spreading  from  the  tympanal  cavity  through 
the  mastoid  cells  internally,  or  by  the  bony  meatus  to  the  periosteum 
covering  the  mastoid  process  externally,  produces  disease  in  that 
bone,  to  which,  and  the  treatment  required,  I  have  already  referred 
at  pages  233  and  245.  In  such  a  condition  the  case  is  one  of  danger, 
but  not  to  such' an  extent  as  that  where  the  inflammation  is  propa- 
gated to  the  dura  mater  through  the  thin  lamina  of  bone  which  sepa- 
rates it  from  the  mastoid  cells,  or  spreads  by  the  way  of  the  labyrinth 
to  the  internal  meatus,  and  meningitis  or  cerebritis  supervene.  The 
lateral  sinus  may  be  the  first  part  affected,  but,  generally  speaking, 
the  anterior  or  posterior  surface  of  the  cranial  aspect  of  the  petrous 
portion  of  the  temporal  bone  exhibit  the  principal  evidence  of  disease, 
being  either  of  a  dark-red  color,  or  a  greenish  hue,  or  sometimes 
merely  a  slight  purplish  tint.  Unhealthy  pus  at  times  forms  between 
the  dura  mater  and  the  bone  :  at  others  the  inflammation  extends  to 
the  brain,  and  abscess  forms  in  the  substance  of  that  viscus ;  while 
in  some  other  cases  the  inflammation  is  of  a  more  diffused  character, 
and  effusions  from  all  the  extensive  serous  surfaces  both  of  the  menin- 
ges and  the  ventricles,  as  well  as  phlebitis  of  the  lateral  sinus,  take 
place.  The  records  of  surgical  and  pathological  science  detail  num- 
bers of  such  cases,  which  are  not,  it  must  be  remembered,  the  result 
of  otorrhoea,  but  of  acute  inflammation  of  the  middle  ear,  extending 
to  the  contents  of  the  cranium,  and  ending  fatally  in  a  few  days,  or 
often  less.     The  lower  orders  in  this  country  are,  from  experience, 


320  ACUTE    OTITIS. 

well  acquainted  with  tlie  fatal  nature  of  this-  malady.  When  com- 
piling the  tables  of  deaths  under  the  Census  Commission  for  1841, 
my  attention  was  attracted  to  the  number  of  cases  in  which  "  died  of 
a  pain  in  the  ear,"  or  "  was  suddenly  struck  with  a  pain  in  the  ear," 
was  returned  as  a  cause  of  death ;  and  I  find  in  the  present  census 
inquiry  that  similar  information,  and  to  rather  a  greater  extent,  has 
been  afforded.  As  many  such  cases  have  resulted  from  persons  having 
fallen  asleep  in  the  open  air,  the  popular  belief  attributes  the  disease 
to  the  entrance  of  insects  or  noxious  animals  into  the  ear,  and  in  the 
case  of  young  children  who  awake  suddenly  screaming  in  a  most 
unearthly  tone,  and  who  are  often  seized  with  convulsions,  and  gene- 
rally die  comatose,  the  vulgar  impression  is,  that  they  have  been 
"  taken  by  the  fairies."'  The  Irish  term  for  the  disease,  Daigh 
cluaise,  "  a  darting  pain  through  the  ear,"  is  expressive  and  charac- 
teristic. 

By  comparing  the  foregoing  description  with  that  previously  given 
of  myringitis,  it  will  be  seen  that  the  two  affections  have,  in  their 
severest  form,  a  number  of  symptoms  in  common,  but  in  that  now 
under  consideration,  they  are  generally  more  aggravated ;  there  is  a 
greater  feeling  of  fulness  and  bursting ;  the  pain  is  of  a  more  violent 
character,  and  the  extent  both  of  it  and  of  soreness  to  the  touch  over 
the  mastoid  region  and  the  side  of  the  head,  are,  if  closely  attended 
to,  sufficient  to  mark  a  differential  diagnosis.  The  more  frequent 
extension  of  the  inflammation  to  the  external  auditory  canal  and  the 
auricle,  as  well  as  the  peculiar  appearances  of  the  membrana  tym- 
pani  itself,  will  still  further  assist  in  the  formation  of  an  opinion. 
But  when  the  inflammation  extends  to  the  parietes  or  contents  of  the 
cranium,  it  is  of  great  moment  that  the  practitioner  should  be  aware 
of  every  symptom  superadded  to  those  peculiar  to  the  aural  disease  alone, 
even  in  the  early  stage  of  the  affection,  as,  when  coma,  convulsions,  or 
stertor  ensue,  the  head  symptoms  are  too  well  marked  to  render  mis- 
take possible;  but  the  mischief  has  generally  been  done  at  that 
period,  and  treatment  will  avail  little.  I  have  seen  delirium,  appa- 
rently more  the  result  of  suffering  than  any  interference  with  the 
sensorium,  so  frequently  attend  inflammation  of  the  membrana  tym- 
pani,  and  even  the  meatus,  that  I  do  not  think  it  is  of  itself  a  pa- 

'  Although  these  popular  fancies  and  folks'  lore  are  fast  passing  away,  it  is  still  of 
some  importance  that  medical  men,  practising  in  the  country,  should  be  famihar  with 
the  opinions  of  the  peasantry  upon  the  subject,  as  well  as  the  names  of  the  diseases 
which  they  have  to  treat. 


ACUTE    OTITIS.  321' 

thognomonic  of  sufficient  importance  to  lead  to  the  belief  that  the 
brain  is  affected;  but  incoherence,  or  much  hesitation  and  irregu- 
larity of  answering,  or  of  understanding  what  is  said,  is  generally 
characteristic  of  cerebral  disease.  So  is  intolerance  of  light  and 
contraction  of  the  pupils,  tossing  of  the  head  from  side  to  side,  and 
a  feeling  of  weight  as  well  as  pain  referred  to  the  whole  head.  Ver- 
tigo is  also  a  symptom  deserving  of  attention. 

In  addition  to  the  general  expressions  of  pain,  particularly  dmnng 
a  paroxysm,  there  is  a  constant  low  moaning,  highly  characteristic  of 
cerebral  affections.^  Rigors  occur  when  abscesses  are  forming  within 
the  cranium,  but  do  not  usually  attend  suppuration  of  the  ear  itself, 
or  of  the  eye  or  orbit.  Dr.  Graves,  in  the  last  edition  of  his  Clinical 
Medicine,  has  called  attention  to  the  occm-rence  of  rigors  during 
fever,  when  detailing  the  case  of  a  patient  who,  in  addition  to  the 
usual  symptoms  of  headache,  hot  skin,  thirst,  nausea,  acceleration  of 
pulse,  and  gastro-intestinal  irritation,  had  a  daily  succession  of  slight 
and  transient  rigors.  His  words  are : — "  Now,  whenever  you  meet 
with  a  symptom  of  this  description  in  fever,  be  on  your  guard ;  watch 
the  case  with  anxious,  unremitting  attention,  and  never  omit  making 
a  careful  examination.  It  is  in  this  way  that  one  of  the  worst  com- 
plications of  fever — treacherous  and  fatal  disease  of  the  brain — very 
often  commences.  On  examining  this  girl,  we  found  that  she  had 
not  only  headache  but  also  acute  pain  referred  to  the  left  ear,  the 
external  meatus  of  which  was  observed  to  be  hot  and  tender  to  the 
touch.  In  addition  to  this,  we  were  informed  by  the  nurse  that  she 
had  been  seized  with  a  sudden  fit  of  vomiting  shortly  after  we  left 
the  ward  on  the  day  before.  Here  was  an  array  of  threatening- 
symptoms  calculated  to  awaken  attention  in  any,  even  the  most  heed- 
less, observer.  A  patient,  after  exposure  to  cold,  is  attacked  with 
symptoms  of  fever ;  she  has  headache  and  restlessness ;  she  then- 
begins  to  complain  of  acute  pain  in  the  ear,  darting  inwardly  towards 
the  brain  ;  and,  finally,  is  seized  with  sudden  vomiting.  Under  these 
circumstances,  it  is  not  difficult  to  form  a  diagnosis,  and  there  can  be 
little  doubt  but  that  the  phenomena  here  presented  were  indicative  of 
incipient  inflammation  of  the  membranes  of  the  brain.  It  is  not  easy 
to  say,  whether  in  such  cases  the  inflammatory  affection  of  the  mem- 
branes precedes  the  external  otitis,  or  whether  the  inflammation  com- 

1  Dr.  Graves  relates  a  case  of  earache  in  fever,  in   which  ,the  symptom  of  moaning 
was  diagnostic  of  head  disease.     London  Medical  and  Surgical  Journal,  vol.  iii.  p.  103. 

21 


322  ACUTE    OTITIS. 

mences  in  the  external  ear  and  spreads  inwards,  though  I  am  inclined 
to  adopt  the  latter  supposition,  and  the  circumstance  of  the  fever  and 
earache  arising  from  cold  seems  to  give  an  additional  degree  of  pro- 
bability to  this  view  of  the  question"  (vol.  i.  p.  191).  Sickness  of 
stomach,  is  not,  however,  a  symptom  I  have  often  remarked  in  auro- 
cerebral  inflammations. 

Thus  far  do  we  observe  the  symptoms,  and  note  the  immediate 
terminations,  of  acute  otitis ;  but  even  after  the  patient  may  have 
recovered  from  the  second  termination, — that  by  suppuration  through 
the  membrana  tympani, — it  cannot  be  said  that  he  is  safe,  for  chronic 
disease  may  go  forward  in  the  part,  inflammation  or  caries  of  the 
bones  may  extend,  and  produce  disease  within  the  cranium  at  a  more 
or  less  distant  period. 

With  respect  to  treatment,  that  recommended  in  acute  myringitis, 
carried  out  to  the  fullest  extent,  is  imperatively  demanded.  Leeches 
should  be  applied  plentifully;  two  or  three  to  a  child,  four  or  six  in  a 
young  person ;  and  from  twelve  to  twenty  in  an  adult ;  round  the 
meatus,  in  front  of  the  tragus,  and  behind  the  aiiricle  over  the  mas- 
toid process ;  and  repeated  by  small  relays  from  time  to  time,  even 
in  the  course  of  the  four-and-twenty  hourS.  Mercury  is  even  more 
necessary  here  than  in  cases  of  myringitis  ;  it  should  be  commenced 
at  once,  and  with  a  twofold  object :  to  arrest  the  disease  in  the  ear, 
and  should  it  fail  in  so  doing,  to  check  its  inward  progress  to  the 
brain.  If  we  find  the  aura.1  disease  succumb  to  the  depletion,  mercury, 
and  other  means  employed,  we  may  hold  back  the  mercury  by  lessen- 
ing its  quantity  or  increasing  the  interval  between  its  doses,  but  not 
omitting  its  use  altogether  so  long  as  any  symptoms  remain  which 
might  indicate  extension  of  the  disease.  Blisters  behind  the  ears, 
fomentations,  and  poultices,  &c.,  as  detailed  in  the  former  sections, 
may  be  called  into  requisition,  according  as  they  afford  relief  in  each 
particular  case.  So  soon  as  it  can  be  determined  that  matter  has 
formed  under  the  periosteum,  or  that  the  structure  itself,  or  the  bone 
of  the  mastoid  process  beneath  it,  is  deeply  implicated  in  the  inflam- 
mation, the  surgeon  should  not  hesitate  to  make  a  free  incision,  as  I 
have  recommended  at  page  233.  Promptness  and  decision  in  this 
matter  will  often  save  a  patient's  life,  even  in  an  advanced  stage  of 
the  disease.  It  has  been  suggested  to  open  the  membrana  tympani 
in  order  to  give  an  early  exit  to  the  imprisoned  fluid ;  and  when  it 
can  be  done  without  facility,  and  without  injuring  the  parts  beyond, 
I  see  no  objection  to  the  practice,  although  I  myself  have  no  expe- 


SUBACUTE    OTITIS.  323 

rience  of  it.     A  difficulty,  however,  presents  in  the  usually  tMckened 
and  inflamed  condition  of  the  external  meatus. 

The  case  referred  to  at  page  290  is  also  a  good  example  of  auro- 
cerebral  inflammation. 

SUBACUTE    OTITIS. 

Notwithstanding  the  severity  of  the  symptoms  in  the  foregoing 
disease,  rupture  of  the  tympanal  ca^dty  from  inflammation  of  its  mu- 
cous lining  often  takes  place,  with  a  much  shorter  and  less  painful 
form  of  disease,  in  which  the  patient  says  he  was  relieved  after  a  few 
hours'  suffering  by  the  "  abscess  in  the  ear  having  opened ;"  that  ever 
since  he  has  been  very  deaf ;  and  that  whenever  he  coughs  or  blows 
his  nose,  the  air  and  discharge  gurgles  through  his  ear.  Upon  exa- 
mination we  generally  find  a  ruptui'e  of  the  membrana  tympani  at  its 
posterior  margin,  the  meatus  is  often  a  good  deal  thickened,  and  the 
membrana  tympani  even  more  engaged  in  the  inflammatory  affection 
than  in  the  former  case.  This  increased  morbid  action  in  the  mem- 
brana tympani,  together  with  some  ulceration  of  its  mucous  surface, 
may  have  led  to  the  early  rupture  and  evacuation  of  the  contents  of 
the  tympanic  cavity ;  the  mastoid  cells  are  seldom  engaged  in  this 
form  of  the  disease.  We  find  an  analogue  to  this  affection  in  inflam- 
mation of  the  eye.  In  some  cases  of  suppuration  of  the  globe,  or  of 
matter  contained  in  the  anterior  chamber,  the  cornea  remains  entire 
for  several  days,  while  in  other  cases  of  very  much  less  amount  of 
mischief,  the  cornea  opens  by  ulceration,  the  contents  of  the  chamber 
are  evacuated,  the  pain  ceases  as  soon  as  the  tension  is  removed,  and 
the  eye  recovers  without  further  mischief,  or  but  a  slight  adhesion 
between  the  iris  and  the  corneal  cicatrix. 

The  occurrence  of  otorrJioea  during  the  progress  of  phthisis,  must 
have  attracted  the  attention  both  of  the  physician  and  the  aural 
practitioner.  In  such  cases  I  generally  find  the  membrana  tympani 
perforated,  and  a  thin  purulent  discharge  pouring  out  of  the  meatus, 
.  and  also  pumped  through  the  aperture  in  the  membrana  tympani  in 
considerable  quantity.  Upon  inquiring  into  the  history  of  the  case, 
it  will  generally  be  found,  that  comparatively  little  pain  was  expe- 
rienced, commensurate  with  the  amount  of  injuiy  done  to  the  parts ; 
deafness  and  discharge  being  often  the  first  symptom  which  attracted 
the  patient's  attention.     It  is  probable  that  in  all  these  cases  subacute 


324  OTITIS    ATTENDING    THE    EXANTHEMATA. 

ulcerative  inflammation  extended  into  the  tympanal  cavity  through 
the  Eustachian  tube,  and  so  thinned  the  memhrana  tympani  that  it 
gave  way  in  a  fit  of  coughing,  without  the  patient  being  at  all  con- 
scious of  the  occurrence  at  the  moment.  No  hope  of  amendment  can 
be  held  out  in  such  cases,  nor  indeed  should  treatment  be  attempted, 
except  that  of  keeping  the  parts  cleansed,  and  using  some  very  mild 
astringent  lotion,  or  a  weak  solution  of  chloride  of  lime,  which  serves 
to  correct  the  foetor  sometimes,  but  not  always,  attending  this  form  of 
otorrhoea. 

In  otitis,  or  inflammation  of  the  tympanal  cavity  in  any  of  its 
forms,  whether  violent  or  mild,  lymph  must  be  effused  upon  the  sur- 
face of  the  membrane,  as  well  as  pus  poured  into  the  cavity,  in  the 
same  way  as  we  find  lymph,  pus,  and  serum  in  the  bag  of  the  pleura 
or  the  peritoneum ;  for  I  am  inclined  to  think,  that  as  soon  as  inflam- 
mation attacks  the  tympanic  cavity,  the  Eustachian  outlet  is  so  much 
closed,  that  it  becomes  a  shut  sac,  liable  to  all  the  phenomena  at- 
tending inflammation  in  serous  cavities.  Hence  those  bands  of 
adhesioii  passing  between  the  sides  of  the  cavity,  as  well  as  its  con. 
tents,  so  often  observed  after  death,  and  to  which  I  have  so  frequently 
referred  in  the  foregoing  chapter,  and  which  must  produce  collapse  of 
the  membrana  tympani  and  impairment  of  hearing. 

Exanthematous  otitis,  to  which  I  have  already  referred  at  page 
268,  is  manifestly  an  acute  inflammation  of  the  mucous  lining  of  the 
tympanal  cavity, — an  extension  of  the  same  unhealthy  affection  so 
frequently  seen  in  the  throat  of  persons  laboring  under  scarlatina  and 
measles,  &c.,  spreading  upwards  through  the  Eustachian  tube,  and 
which  not  only  attacks  the  internal  surface,  but  shows  itself  in  the 
form  of  glandular  swellings,  diffuse  inflammation,  and  purulent  de- 
posits in  the  neck.  I  must  again  repeat  what  I  have  already  men- 
tioned, that  practitioners  do  not  sufficiently  attend  to  the  state  of  the 
ear  in  scarlatina,  and  that  they  neglect  the  application  of  remedies 
for  a  disease  which  is,  even  in  the  unhealthy  condition  which  the 
patient  usually  is  at  the  moment,  amenable  to  treatment,  and  the 
omission  of  which  has,  in  numbers  of  instances,  led  to  permanent 
deafness,  and  when  the  patient  is  young,  to  consequent  muteism. 
That  I  am  not  overstating  the  case  may  be  learned  by  any  person 
who  will  examine  the  records  of  deaf  and  dumb  institutions,  or  in- 
quire into  the  causes  of  acquired  muteism.  Thus,  from  the  latest 
authentic  Continental  Table — that  published  by  the  Belgian  govern- 


OTITIS    IN    SCAELATINA.  325 

ment  in  1847,^  we  learn  that  of  1892  cases  of  acquired  miiteism  from 
all  causes,  216  were  from  scarlatina,  80  from  measles,  and  28  from 
small-pox;  from  the  American  Tables — out  of  86  cases  of  non-con- 
genital muteism,  as  many  as  41  were  from  scarlatina  f — and,  accord- 
ing to  the  investigations  in  which  I  have  been  engaged  under  the 
present  Census  Commission  in  Ireland,  I  find  that  of  394  cases  of 
specified  causes  of  acquired  muteism,  in  35  instances  it  arose  from 
scarlatina;  in  12  from  small-pox;  and  in  7  from  measles;  in  all  54;^ 
from  exanthematous  otitis,  or  1  in  7*30  of  the  whole ;  and  I  am  inclined 
to  think,  that  this  proportion  is  even  less  than  what  actually  exists, 
for  many  cases  were  retmmed  as  "Diseases  of  the  Ear,"  or  a  "Dis- 
charge from  the  Ear,"  acquired,  no  doubt,  during  some  of  those 
febrile  diseases  just  specified.  The  most  unmanageable  cases  of 
otorrhosa  which  I  have  met  with  in  practice,  those  in  which  most 
destruction  has  taken  place,  and  where  the  ossicula  have  been  most 
frequently  lost,  have  been  the  result  of  scarlatina  or  measles. 

Life  may  be  lost  from  exanthematous  otitis,  even  as  a  secondary 
affection,  of  which  a  remarkable  example  is  afibrded  by  Professor 
Porter,  in  the  first  volume  of  Dr.  Graves's  CHnical  Medicine,  in  which 
a  boy  had  an  attack  of  otitis  while  suffering  from  scarlatina ;  he  re- 
covered the  latter  affection,  but  had  facial  paralysis,  with  profuse 
otorrhoea,  and  was  weak  and  emaciated.  At  the  end  of  six  weeks, 
profuse  hemorrhage  burst  from  the  external  meatus;  "the  child  had 
been  asleep,  when  he  suddenly  awoke,  screamed  out  '  Oh !  my  ear, 
my  ear !'  when  almost  instantly  a  gush  of  blood  took  place  from  the 
right  ear.  The  blood  was  florid  and  had  the  appearance  of  being 
arterial."  Professor  Porter,  who  was  present  dm'ing  one  of  the 
attacks  of  hemorrhage,  writes:  "He  seemed  to  have  no  previous 
warning  whatever :  sometimes  the  bleeding  commenced  during  sleep, 
sometimes  while  he  was  amusing  himself  with  his  toys.  He  generally 
gave  a  single  scream  at  the  instant,  and  then  the  blood  bm'st  forth 
with  a  gush  that  really  astonished  me.  I  never  saw  blood  lost  so 
rapidly  in  any  sm-gical  operation  I  ever  witnessed,  and  only  once  in 
an  accident,  where  the  deep  jugular  vein  had  been  opened.  This 
bleeding  could  hardly  be  controlled  by  pressm'e,  and  the  attempt  to 

'  See  Dr.  Sauveur's  Investigations  in  the  Appendix  on  Deaf-Dumbness,  at  the  conclusion 
of  this  work. 

2  American  Annals  of  the  Deaf  and  Dumb,  Vol.  I.,  No.  1,  p.  31. 

3  See  Report  of  the  Irish  Census  Commissioners  upon  The  Status  of  Disease,  page  20; 
and  also  Appendix  of  this  work  on  Deaf-Dumbness, 


326  DEAFNESS    IN    FEVER. 

do  SO  caused  intense  pain,  so  that  at  times  the  nurse  did  not  interfere, 
but  allowed  it  to  stop  spontaneously,  which  it  generally  did  in  about 
a  minute.  About  a  week  before  his  death,  I  observed  that  the  blood 
was  beginning  to  make  its  way  by  the  Eustachian  tube  into  the 
pharynx,  some  of  which  passed  into  the  stomach,  and  some  was  ex- 
pelled by  the  mouth,  and  then  he  bled  sometimes  by  one  passage, 
sometimes  by  the  other,  and  occasionally  by  both.  I  need  not  say 
that  he  became  pale,  exsanguine,  and  exhausted,  except  to  express 
surprise  that  any  child  of  his  age  could  have  endured  so  long.  The 
palate  and  inside  of  his  mouth  was  as  pale  as  any  part  of  the  external 
surface  of  his  body.  Exactly  at  the  end  of  the  thirteenth  week  from 
the  commencement  of  his  illness,  he  died  after  a  slight  gush  of  blood." 
There  was  no  post  mortem  examination,  but  the  author  believed,  and 
with  every  reasonable  probability,  that  the  carotid  artery  had,  by 
ulceration,  opened  into  the  Eustachian  tube,  where  those  two  canals 
are  only  separated  by  a  very  thin  septum  of  bone. 

A  case  is  related  in  the  Edinburgh  Monthly  Journal,  No.  III.,  of  a 
child  eleven  years  of  age,  who  had  a  severe  attack  of  scarlatina,  with 
suppurative  otitis  in  both  ears,  from  whose  right  ear  a  sudden  dis- 
charge of  blood  occurred  on  the  fifteenth  day.  The  hemorrhage  re- 
turned three  times  in  great  quantity  during  the  six  following  days. 
Mr.  Syme  tied  the  carotid  artery,  which  checked  the  bleeding,  but 
the  case  terminated  fatally  on  the  eleventh  day  after  the  operation, 
apparently  from  cerebral  disease.  Upon  examination,  it  was  disco- 
vered that  the  carotid  was  not  concerned  in  the  disease,  but  that  the 
blood  came  from  the  lateral  sinus,  the  bony  septum  between  which 
and  the  cavity  of  the  ear  had  ulcerated  through  at  one  point. 

Of  the  deafness  from  fever  I  have  already  spoken  at  page  269? 
•^hen  describing  the  condition  presented  by  the  membrana  tympani  as 
the  result  of  that  affection ;  and  the  remarks  there  made  are  equally 
applicable  here.  That  the  effects  of  this  disease  are  much  more  com- 
mon than  is  generally  supposed,  may  be  learned  from  the  Irish  Census 
Returns  already  alluded  to  at  page  325 ;  for,  of  the  394  cases  of  ac- 
quired muteism  from  specified  causes,  in  61  persons,  31  males  and  30 
females,  the  disease  was  attributed  to  fever.  Besides  which,  a  num- 
ber of  cases  of  partial  deafness,  the  result  of  fever,  present  daily  at 
our  public  institutions.  In  a  country  where  fever  prevails  so  exten- 
sively, it  is  a  matter  of  surprise  that  so  few  cases  of  muteism  have 
resulted ;  and  the  circumstance  can  only  be  attributed  to  the  fact  of 
those  attacked  having  been  at  the  time  of  adult  age,  and  who,  conse- 


DEAFNESS    IN    FEVER.  327 

quentlj,  never  completely  lost  the  power  of  speech,  although  many- 
are  partially  deaf. 

Another  result  of  typhus  fever  is  dionbness,  one  of  the  most  notable 
cases  of  which  has  been  related  by  Dr.  Foley,  of  Kilrush.  The 
following  are  the  particulars : — A  boy,  aged  13,  had  a  bad  attack  of 
typhus  in  1839,  and  after  a  severe  struggle  recovered,  but  with  para- 
lysis of  the  right  side,  and  total  loss  of  the  power  of  speech ;  it  was, 
however,  believed  that  he  was  not  deaf,  as  he  could  still  hum  tunes. 
He  soon  recovered  from  the  paralysis,  but  remained  dumb  for  eight 
years,  when  my  attention  was  directed  to  the  peculiarities  of  his  case 
while  engaged  in  making  inquiries  into  the  circumstances  of  the  deaf 
and  dumb  under  the  present  Census  Commission.  I  communicated 
with  Dr.  Foley,  who  kindly  afforded  me  many  interesting  particulars 
of  the  case,  and  also  published  the  following  additional  account  of  it 
in  one  of  the  periodicals: — '"During  recent  inquiries  made  about  the 
case,  I  find  that  the  patient  continued  completely  dumb  for  the  space 
of  eight  years,  after  which  he  and  every  member  of  his  family  were 
seized  with  typhus  fever.  Towards  the  termination  of  the  disease  he 
was  observed  to  articulate  one  or  two  short  words  at  different  times. 
As  convalescence  progressed,  pains  were  taken  to  teach  him  a  few 
more,  and  by  very  slow  degrees,  indeed,  he  was  gradually  brought  on, 
so  that  now,  at  the  end  of  three  years,  he  can  speak  very  distinctly, 
but  at  times  so  rapidly  as  to  cause  him  great  embarrassment.  The 
intensity  of  the  disease  must  have  been  much  less  in  the  last  attack 
than  in  the  former,  as  in  the  first  he  was  quite  unconscious  nearly 
from  the  commencement;  while  in  the  latter,  he  has  stated  to  me, 
that  he  never  lost  his  recollection.  He  has  a  perfect  memory  of 
every  circumstance  since  his  fever  in  1839 ;  was  well  aware  of  the 
privation  under  which  he  labored,  and  therefore  shunned  intercourse 
with  all  except  members  of  his  own  family.  He  understood  very  well 
the  jeers  and  observations  made  by  those  thoughtless  young  persons 
among  whom  he  was  obliged  to  be ;  galling  as  they  were  to  his  feelings, 
he  had  no  way  to  defend  himself,  and  could  not  convey  that  he  com- 
prehended every  word  as  well  as  any  of  them.  I  questioned  him  on 
different  occurrences  that  took  place  since  he  had  been  my  patient  in 
1839,  and  found  that  his  memory  on  and  acquaintance  with  them  was 
quite  accm-ate ;  so  that  I  have  no  doubt  of  the  correctness  of  his  com- 
prehension during  the  eight  years  of  his  dumbness.  He  told  me  that, 
since  the  orginal  disease,  he  felt  a  '  weakness '  in  the  right  side  of  his 
body  that  never  prevented  his  power  of  moving,  but  yet  made  him 


328  POST-FEBRILE    DUMBNESS. 

feel  'uncomfortable;'  that,  as  the  power  of  speech  returned,  the 
'weakness'  was  diminishing,  so  that  now  he  scarcely  feels  it.  I 
stated  in  the  original  report  that  he  exhibited,  during  the  fever,  a  very- 
severe  and  well-marked  paralysis  of  the  right  side,  including  every 
part  from  the  eye  to  the  toes;  that  on  the  nineteenth  day  it  had 
nearly  disappeared,  and  he  was  soon  after  able  'to  run  about.'  There 
seems  to  be  no  doubt  that  the  leading  feature  was  meningeal  engorge- 
ment, in  the  head  at  all  events,  and  probably  continued  into  the 
spinal  canal.  I  think  it  probable  that  the  striae  of  that  congestion 
remained  at  the  base  of  the  skull,  compressing  some  of  the  filaments 
composing  the  roots  of  the  glosso-pharyngeal  portion  of  the  eighth 
nerve ;  as  also  of  the  ninth  on  the  same  side."^ 

In  the  same  paper  Dr.  Foley  has  related  a  case  of  post-febrile  deaf- 
ness, in  a  boy  about  eight  years  old,  and,  as  the  defect  of  the  hear- 
ing is  complete,  he  is  gradually  losing  speech,  and  can  now  only 
pronounce  a  few  words.  I  do  not  know  the  state  of  the  ear  in  either 
case.  I  possess  the  histories  of  three  cases  in  which  females  became 
dumb  during  parturition :  they  were  also  partially  paralyzed. 

Sir  Charles  Bell  has  related  a  most  interesting  case  of  disease  of 
the  ear  and  loss  of  speech,  which  bears  some  affinity  to  that  recorded 
by  Dr.  Foley,  and  of  which  the  following  is  an  abstract,  nearly  in  the 
words  of  the  narrator.  A  boy,  aged  10,  was  seized  with  obstinate 
pain  in  his  left  ear,  which,  extending  to  his  head,  face,  and  teeth,  gave 
him  no  rest  day  or  night ;  he  also  then  lost  the  sight  of  his  right  eye. 
He  recovered  from  this  attack  apparently  by  a  considerable  discharge 
of  pus  from  the  ear,  attended  with  intense  pain,  delirium,  and  convul- 
sions. Some  time  afterwards  he  had  a  second  similar  attack,  remain- 
ing insensible  for  half  an  hour,  and  when  he  awoke  to  consciousness, 
"he  was  speechless."  When  brought  under  the  care  of  Sir  Charles 
Bell,  he  had  a  discharge  from  his  ear,  and  was  quite  deaf,  and  the 
left  arm  was  paralyzed ;  he  could  masticate  and  swallow  with  ease, 
and  also  protrude  the  tongue  and  turn  it  from  side  to  side ;  but  he 
was  utterly  unable  to  pronounce  words.  The  consent  of  action  be- 
tween the  chest,  larynx,  and  mouth,  seemed  to  be  lost  shortly  after 
the  foregoing  note  of  his  case.  It  was  then  reported  that  he  was 
able  to  whistle,  but,  says  the  author,  "  on  witnessing  this  attempt,  we 
find  that  he  makes  a  faint  noise  by  drawing  in  his  breath ;  and  that, 
in  fact,  he  cannot  whistle."     In  this  state  he  remained  for  six  weeks 

'  See  Medical  Times  and  Gazette,  for  May  8,  1852,  The  original  case  appeared  in 
the  Dublin  Medical  Press  of  September  9,  1840. 


CONGENITAL    DUMBNESS.  329 

longer,  "when  we  read,  that  "  his  eftorts  confirm  the  former  statement, 
that  he  is  incapable  of  putting  the  tongue  and  larynx  into  co-operation 
in  speech.  The  mouth  is  shut,  the  tongue  and  larynx  perfectly  still, 
and  he  makes  a  noise  by  impelling  the  air  against  the  posterior  nares." 
Nine  months  after  the  time  when  he  lost  his  speech,  he  recovered  it 
in  the  following  manner,  as  related  by  his  mother : — "  Three  morn- 
ings ago  he  recovered  his  hearing  and  his  power  of  speech  at  the 
same  time.  She  had  just  been  observing  that  he  could  not  be  very 
ill,  since  he  was  tumbling  about,  and  throwing  his  heels  over  his  head 
in  bed.  Soon  after,  his  sister  came  running  down  stairs,  saying,  that 
her  brother  could  speak,  and  a  quantity  of  matter  had  come  from 
his  head  into  his  mouth.  From  that  moment  he  could  hear,  and  with 
a  painful  degree  of  acuteness,  the  boy  saying  that  the  air  rushed 
through  his  head.  She  describes  his  voice,  too,  as  at  first  unnatural, 
and  as  if  he  spoke  with  difiiculty ;  a  circumstance  which  cannot  sur- 
prise us,  when  we  recollect  that  it  is  nine  months  since  he  could  speak 
a  word."  Bell  has  appended  the  following  remarks  to  this  cmious 
case.  "  There  appears  to  have  been  an  abscess,  originally  produced 
by  disease  of  the  temporal  bone,  and  affecting  the  nerves  of  the  base 
of  the  brain,  first  affecting  the  fifth  nerve,  and  then  spreading  its 
influence  to  the  seventh  and  ninth.  If  the  disease  had  produced  its 
influence  mechanically,  and  by  pressure,  there  would  have  been  no 
obscurity,  and  one  side  only  would  have  been  affected ;  but  I  imagine 
that  the  inflammation  had  disturbed  the  operations  of  the  nerves, 
without  altogether  destroying  their  influence,  deranging,  for  instance, 
the  fine  associations  necessary  to  speech,  without  arresting  the  action 
of  the  muscles  of  the  tongue.  It  is  remarkable,  that  the  bursting  out 
of  matter,  probably  from  the  Eustachian  tube,  had  such  an  instanta- 
neous and  simultaneous  effect  in  restoring  both  hearing  and  speech."^ 
Cases  of  congenital  dumbness,  without  deafness,  although  rare, 
have  now  been  fully  authenticated  ;  and  a  very  remarkable  instance 
of  the  sudden  acquisition  of  speech  is  the  celebrated  case  related  by 
De  Foe,  of  "The  Dumb  Philosopher,  or.  Great  Britain's  Wonder; 
containing:  A  faithful  and  very  surprising  account  how  Dickory 
Cronke,  a  tinner's  son,  in  the  County  of  Cornwall,  was  born  dumb, 
and  continued  so  for  fifty-eight  years ;  and  how,  some  days  before  he 
died,  he  came  to  his  speech ;  with  memoirs  of  his  life  and  the  manner 
of  his  death." 

1  The  Nervous  System  of  the  Human  Body.  By  Charles  Bell,  F.  R.  S.  London : 
1830,  p.  cxviii.  See  also  Dr.  Abercrombie's  cases  in  the  Edinburgh  Medical  and  Sur- 
gical Journal  for  July,  1818. 


330  OTITIS    WITH    FACIAL    PARALYSIS. 

The  other  circumstances  relating  to  congenital  muteism,  will  be 
found  in  the  Appendix  upon  Deaf-dumhness  at  the  conclusion  of  this 
work.  To  my  learned  friend,  Dr.  Travers,  I  am  indebted  for  the 
following  reference  to  one  of  the  ancient  authorities  upon  deafness 
occurring  during  fever : — 

"  In  reply  to  your  note,  inquiring  about  deafness  as  a  symptom  in 
typhus  fever,  I  might  give  you  references  to  a  long  series  of  authors 
from  the  earliest  times,  but  the  indistinctness  of  the  characters  given  by 
many,  indeed  a  majority,  of  the  earlier  writers,  renders  it  often  diffi- 
cult to  determine  whether  the  disease  they  described  is  identical  with 
the  typhus  of  this  country.  It  will,  probably,  be  sufficient,  instar  om- 
nium, to  cite  Hippocrates,  who  makes  frequent  mention  of  this  symp- 
tom ;  but  he  mentions  it  as  occurring  in  both  favorable  and  fatal 
cases :  thus,  in  the  third  book  of  his  Epidemics,  he  states  it  to  have 
been  persistent  in  the  case  of  Hermocrates,  who  died  on  the  twenty- 
seventh  day  of  the  fever  (Hipp.  Epidem.,  lib.  III.  §  1) ;  while  in  the 
first  book  he  had  described  it  as  occurring  on  the  nineteenth  night, 
in  the  «ase  of  Epicratis,  who  recovered  (lb.  lib.  I.  §  3).  He  mentions 
it  also  in  his  Aphorisms,  §  iv.  28,  49,  and  60  (with  which  compare 
Celsus,  lib.  II.  capp.  6  and  8) ;  also  in  his  Coacse  Praenotiones,  and  in 
several  places  of  his  Prorrhetica,  e.  g.,  1.  4, — -/MfwaKz  h^  d^iffc  xai 
zapa^codsffi  TzapaxoXoodooaa  y.ay.o'j.  See  also,  in  same  book,  §  12  and 
§  18.  In  the  seventeenth  century,  and  afterwards,  you  have  Ettmul- 
ler,  Yan  Swieten,  and  a  host  of  others." 

OTITIS   WITH   INFLAMMATION    OF   THE   FACIAL   NERVE. 

Loss  of  motion  of  those  parts  of  the  face  supplied  by  the  portio 
dura  of  the  seventh  pair  of  nerves,  and  generally  known  as  "Bell's 
Paralysis,"  is  so  frequent  an  affection,  and  its  symptoms  so  well  known, 
that  it  is  unnecessary  here  to  enter  into  a  minute  description  of  its 
character  and  aj)pearance.  Pressure  on  the  nerve  in  any  portion  of 
its  course,  disease  of  the  brain,  caries  of  the  temporal  bone,  or  other 
organic  lesions  of  a  similar  character,  to  be  described  under  the  head 
of  otorrhoea,  are  the  causes  most  usually  assigned  for  this  affection. 
Occasionally,  however,  the  physician  or  surgeon  meets  with  cases  of 
facial  paralysis  which  had  appeared  suddenly  and  without  any  osten- 
sible cause.  Such  cases^are  usually  set  down  as  the  results  of  cold, 
and,  generally  speaking,  the  patient  states  that  he  has  been  exposed 
to  a  draft  of  cold  air,  opposite  a  broken  window,  an  open  door,  or 
upon  the  top  of  a  coach,  &c.,  immediately  before  the  disease  appeared. 
It  still  remains  to  be  proved,  that  the  application  of  cold  to  the  ex- 


OTITIS    WITH    FACIAL    PARALYSIS.  331 

tremities  of  the  nerve  produces  paralysis  of  the  muscles  to  which  it  is 
distributed ; — yet  such  has  been  the  only  mode  of  accounting  for  some 
of  the  cases  of  Bell's  paralysis.  It  is  true,  that  if  we  carefully  ex- 
amine the  records  of  such  cases,  we  shall  find  dulness  of  hearing,  tin- 
nitus aurium,  and  a  slight  pain  in  the  ear,  enumerated  among  the 
symptoms ;  but  until  I  called  attention  to  the  subject  some  years  ago, 
it  was  not  believed  that  the  paralysis  was  produced  by  inflammation 
of  the  ear  extending  into  the  aqueduct  of  Fallopius.  In  my  essay 
upon  the  aflections  of  the  membrana  tympani,  I  stated  that  I  was 
"  strongly  inclined  to  think,  that  many  of  the  cases  of  paralysis  of 
the  seventh  pair  of  nerves,  where  we  have  no  mechanical  lesion,  such 
as  caries  or  exfoliation,  and  which  heretofore  were  usually  attributed 
to  cold,  &c.,  may  have  been  caused  by  some  form  of  otitis ;  and  I 
would,  therefore,  beg  to  direct  the  special  attention  of  physicians  to 
the  peculiar  condition  of  the  ear  in  all  such  instances ;"  and  I  then 
furnished  some  cases  in  proof  of  my  opinion.  Since  that  time  I  have 
had  extensive  opportunities  for  testing  my  belief;  and  I  have  not  met 
with  a  single  instance  of  Bell's  paralysis  unaccompanied  by  otorrhoea, 
caries,  or  cerebral  afiection,  in  which  there  was  not  manifest  traces 
of  disease,  or  its  results,  in  the  membrana  tympani,  or  in  the  middle 
ear.  Why  the  nerve  should  be  afi"ected  in  cases  of  very  slight  in- 
flammation of  the  cavitas  tympani  and  its  external  membrane,  and 
not  in  those  in  which  there  is  violent  otitis  extending  to  the  perios- 
teum and  the  mastoid  cells,  it  is  difficult  to  determine ;  neither  can  I 
offer  any  plausible  reason  for  loud  sudden  noises  producing  such,  as, 
for  instance,  in  the  case  of  Dr.  Bloxham,  of  Portsmouth,  related  at 
page  220.  The  traget  of  the  nerve  around  the  tympanum  is  long 
and  tortuous,  and  one  only  wonders  why  it  is  not  more  frequently 
affected.     The  following  case  affords  a  good  example  of  this  disease. 

P.  R.,  aged  35,  suffered  from  typhus  fever  about  fourteen  years 
ago,  during  which  he  had  violent  pain  in  his  left  ear,  accompanied 
by  a  discharge  which  has  continued  ever  since.  He  is  quite  deaf 
upon  this  side,  and  upon  examination  the  membrana  tympani  is  found 
to  be  perforated  at  its  anterior  portion,  and  the  whole  membrane, 
auditory  passage,  and  middle  ear  as  far  as  can  be  seen  through  the 
aperture,  are  of  a  bright  florid  red ;  the  ossicula,  however,  remain  in 
situ. 

The  hearing  in  his  right  ear  remained  perfect  until  the  beginning 
of  May,  1847,  when  he  began  to  perceive  a  deafness  upon  that  side, 
which  after  a  few  days  was  accompanied  by  a  most  distressing  noise 


332  OTITIS    WITH    FACIAL    PARALYSIS. 

resembling  the  "  escape  of  steam ;"  he  had  also  a  rolling  noise  in  his 
head,  but  no  pain  in  either  head  or  ear.  He  sought  medical  advice, 
and  had  "  drops"  of  an  irritating  nature  poured  into  the  meatus.  Not 
having  derived  benefit  from  these,  he  applied  at  St.  Mark's  Hospital 
on  the  29th  of  the  month.  The  noise  and  deafness  were  as  already 
described ;  in  addition,  he  suffered  from  headache  and  pain  in  his 
face.  The  right  side  of  the  face  was  then  completely  paralyzed, 
presenting  the  usual  appearance  of  fulness  and  smoothness ;  the 
mouth  drawn  to  the  left  side,  the  eye  staring  from  inability  to  close 
the  lids,  the  tears  flowing  over  upon  the  cheek,  the  nostril  collapsed, 
the  color  of  the  skin  somewhat  heightened,  and  its  temperature  con- 
siderably raised  beyond  that  of  the  opposite  side.  The  auditory 
canal  was  dry  and  red ;  the  tympanal  membrane  had  considerably 
lost  its  polish,  and  presented  an  uniform  pink  appearance,  not  unlike 
blotting-paper.  He  had  no  pain  anywhere  around  or  about  the  ear, 
nor  could  pain  or  soreness  be  produced  upon  making  pressure  in  any 
of  the  usual  situations.  He  was  able  to  inflate  the  tympanum ;  but 
could  not  hear  the  watch  placed  to  the  ear  or  any  part  of  the  head, 
and  could  with  great  difficulty  distinguish  the  voice. 

He  was  slightly  mercurialized  by  the  use  of  the  hydrargyrum  cum 
cretfi.,  with  cicuta ;  leeches  were  applied  several  times  round  the 
meatus,  and  small  blisters  over  the  mastoid  process.  As  soon  as  his 
mouth  became  sore  (in  about  ten  days),  the  hearing  returned,  so  that 
he  could  hear  ordinary  conversation  very  well ;  the  vascularity  of 
the  membrane  lessened  considerably,  and  the  noise  decreased.  On 
the  15th  of  June  the  paralysis  had  quite  disappeared ;  he  was  then 
obliged  to  discontinue  his  attendance  at  the  hospital,  but  was  given 
some  of  the  iodine  and  hydriodate  of  potash  solution  to  take  occa- 
sionally. "Wishing  to  learn  the  result  of  this  case,  I  sent  for  the 
patient,  and  again  examined  him  upon  the  10th  of  September  follow- 
ing. He  had  no  return  of  the  paralysis ;  the  hearing  remained  much 
the  same ;  the  meatus  was  still  red ;  the  membrana  tympani,  over 
the  head  and  handle  of  the  malleus,  was  bright  red  ;  the  rest  of  the 
membrane,  with  the  exception  of  one  clear  spot  in  front  of  the  point 
of  the  malleus,  presented  a  dull,  pearly  hue ;  there  was  no  collapse 
observable  in  it,  but  a  very  opaque  rim,  like  a  broad  arcus  senilis, 
surrounded  its  lower  attachment. 

If  we  take  up  Sir  Charles  Bell's  great  work  on  the  Nervous  Sys- 
tem, already  quoted  from,  we  shall  fi.nd  several  of  the  cases  therein 
so  graphically  detailed  confirming  the  foregoing  views.     Professor 


CATARKHAL    OTITIS.  333 

Roux,  of  Paris,  in  writing  the  history  of  his  own  attack  of  facial 
paralysis,  says :  "  Dui'ing  the  course  of  this  complaint,  I  have  exjoe- 
rienced  two  circumstances  which  may  lead  to  the  detection  of  the 
facial  nerve  becoming  affected : — 1.  The  membrane  of  the  tympanum 
was  painfully  sensible  even  to  slight  noises.  2.  The  sense  of  taste 
was  affected  in  the  right  side  of  the  tongue,  so  that  everything  tasted 
metallic.  This  last  symjDtom  has  ever  been  a  precursor  of  the  com- 
plaint, being  observed  twenty-four  hours  before  the  occurrence  of 
paralysis."  The  disease  was  attributed  to  rheumatism ;  but  it  is 
manifest  that  the  inflammatory  action  commenced  in  the  ear,  affecting 
first  the  chorda  tympani,  and  then  the  portio  dura.  The  case  of  J. 
Richardson,  No.  3,  recorded  at  page  68  of  Bell's  book,  is  evidently 
one  of  acute  otitis,  producing  facial  paralysis ; — Casq  No.  33  is  of  a 
like  nature,  but  neither  in  it,  nor  in  any  of  the  other  cases  of  facial 
paralysis  detailed  in  that  work,  was  any  examination  made  of  the 
membrana  tympani  or  the  middle  ear. 

Independently  of  the  cases  of  well-marked  facial  paralysis,  such 
as  those  detailed  in  the  foregoing  section,  I  have  frequently  observed 
a  trivial  affection  of  the  nerve  in  connexion  with  aural  disease,  which 
had  evidently  commenced  by  inflammatory  action  in  the  tympanum, 
or  its  external  membrane.  In  such  cases,  if  we  stand  directly  oppo- 
site the  patient,  while  the  face  is  in  a  state  of  rest,  there  is  no  twist- 
ing of  the  mouth,  nor  any  paralytic  condition  of  the  eyelids,  but  the 
cheek  looks  slightly  fuller  than  that  upon  the  opposite  side ;  and  the 
ordinary  wrinkle,  or  curved  indentation,  extending  from  the  corner 
of  the  nose  to  a  point  a  little  external  to  the  commissure  of  the  lips, 
is  either  altogether  deficient,  or  not  so  well  marked  as  that  upon  the 
opposite  side  ;  and  if  we  engage  the  patient  in  conversation  so  as  to 
bring  the  muscles  of  expression  into  view,  all  the  foregoing  appear- 
ances become  exaggerated.  I  have  seen  many  such  cases,  where  this 
symptom  had  not  been  observed  by  the  patient  or  his  friends,  or  his 
medical  attendant. 

Of  the  rheumatio  and  gouty  otitis  I  have  already  written,  and 
afforded  a  good  example  of  the  former  at  page  242,  in  the  case  of 
Mr.  F.,  and  this  is  a  form  of  the  disease  not  unusually  attended  with 
affections  of  the  facial  nerve. 

CATARRHAL   AND    CHRONIC   INFLAMMATIONS    OF   THE   MIDDLE    EAR. 

Catarrhal  inflammation,  extending  through  the  Eustachian  tube 
into  the  middle  ear,  and  producing  muculent  accumulation  within 


334  CATAREHAL    OTITIS. 

that  cavity,  is  a  frequent  disease,  particularly  of  youth  and  early  life. 
As  it  is  generally,  although  not  always,  attended  with  symptoms  of 
subacute  inflammation  in  the  memhrana  tympani,  the  characters  of 
both  diseases  have  so  much  in  common,  that  I  must  refer  the  reader 
to  the  descriptions  of  subacute  myringitis  at  page  247,  and  of  stru- 
mous myringitis  at  page  260.  A  number  of  authors  have  written 
upon  this  affection  under  different  appellations,  such  as, — chronic 
internal  catarrh ;  catarrhal  otitis  ;  and,  mucous  accumulation  in  the 
cavity  of  the  tympanum ;  Mr.  Pilcher,  as  "  the  milder  form  of  acute 
otitis  interna;"  and  by  Dr.  Kramer,  who  has  given  a  very  good 
account  of  the  disease,  it  is  described  under  the  head  of  "  inflamma- 
tion of  the  mucous  membrane  of  the  middle  ear,  with  accumulation  of 
mucus ;"  but,  like  most  writers  upon  the  subject,  he  has  prefaced  his 
observations  by  a  lengthened  dissertation  upon  Eustachian  cathete- 
rism,  and  the  introduction  of  gaseous  and  fluid  injections,  and  catgut 
bougies,  into  the  cavity  of  the  tympanum. 

The  familiar  instance  of  "  a  cold  in  the  head,"  in  which  there  is 
coryza  ;  impairment  of  smell ;  stufiing  of  the  nose  and  frontal  sinuses ; 
thickening  and  some  increased  redness  of  the  faucial  mucous  mem- 
brane ;  a  singing  or  buzzing  in  the  ears ;  and  partial  deafness,  re- 
lieved occasionally  upon  blowing  the  nose,  coughing,  or  sneezing, 
when  a  feeling  is  experienced  as  if  something  "cracked  or  gave  way" 
within  the  drum, — affords  a  good  example  of  many  of  the  phenomena 
attending  one  form  of  this  disease.  When  it  attacks  young  persons, 
or  children  at  school,  it  is,  as  already  mentioned  at  page  260,  too 
frequently  attributed  to  inattention,  and  time  is  allowed  to  pass  by 
that  might  be  advantageously  employed  with  treatment ;  or  the 
patient's  friends  excuse  themselves  by  saying  they  thought  it  was 
"only  a  cold."^  In  most  instances,  the  disease  spreads  through  the 
Eustachian  tube,  the  membrane  of  which  being  thus  closed,  the  free 
ingress  of  air  to  the  tympanum  is  interrupted.  There  is  generally  a 
sensation  of  fulness  in  the  ear,  and  the  hearing  distance  is  at  first 
very  variable,  being  always  increased  after  each  rush  of  air  into  the 
tympanum ;  but  as  the  disease  progresses,  if  not  relieved  by  nature, 
or  controlled  by  art,  a  general  dulness,  often  mistaken  in  young 

*  One  of  the  truest  and  most  graphic  recitals  of  a  case  of  neglected  ain-al  disease 
which  I  have  met  with  is  that  of  "  The  Deaf  Playmate's  Story,"  by  Miss  Martineau,  in 
a  Christmas  brochure,  styled  "  A  Round  of  Stories,"  &c.,  conducted  by  Charles  Dickens, 
and  which  I  would  strongly  recommend  to  the  perusal  of  parents,  schoolmasters,  and 
guardians. 


CATARRHAL    OTITIS.  335 

persons  for  stupidity,  remains.  Upon  applying  tlie  stethoscope,  while 
the  patient  forces  a  stream  of  air  into  the  cavitas  tympani,  by  holding 
the  nose,  and  making  a  forced  expiration,  or  by  the  surgeon  intro- 
ducing a  catheter,  and  employing  the  air-press,  a  gm-gling  or  crackling 
sound  is  distinctly  heard  in  that  cavity,  and  very  frequently  it  can 
be  discerned  within  the  mastoid  cells  also,  showing  that  thin  mucus 
has  accumulated  in  these  localities,  no  doubt  poured  out  from  the 
irritated  and  inflamed  lining  membrane.  Pain  is  seldom  complained 
of,  but  the  mucous  membrane  of  the  thi'oat  is  a  degree  redder  than 
natural,  although  there  is  no  soreness  or  uneasiness  experienced  in 
swallowing ;  but  the  uvula  is  almost  invariably  relaxed.  If  this  latter 
organ  be  carefully  examined  in  a  number  of  cases,  it  will  generally 
be  found  that  there  is  little  or  no  enlargement  of  its  body  or  muscular 
portion,  but  that  the  elongation  consists  in  a  tag  of  the  mucous  enve- 
lope dependent  from  its  extremity,  between  it  and  which  there  is  often 
a  distinct  depression.  The  external  glands  of  the  throat  are  often 
enlarged. 

Patients  laboring  under  catarrhal  inflammation  of  the  ears  are 
much  influenced  by  the  state  of  the  atmosphere,  or  variations  of  tem- 
perature, being  always  worse  in  damp  moist  weather.  The  state  of 
the  external  meatus  and  membrana  tympani  will  be  found  upon 
inspection  such  as  I  have  described  under  the  head  of  strumous 
myringitis  at  page  260,  to  which  section  I  would  here  refer  the 
reader ;  but  subacute  or  chronic  inflammation  of  the  mucous  lining  of 
the  tympanum  is  a  constant  attendant  upon  other  forms  of  inflamma- 
tion of  its  external  septum.  Neither  in  his  description  of  the  disease, 
nor  in  the  details  of  cases,  of  which  there  are  several,  has  Dr.  Kramer 
given  a  very  accurate  account  of  the  state  of  the  membrana  tympani 
in  this  disease ;  and  several  of  the  cases  related  by  him  afi"ord  no  note 
of  the  state  of  this  structure  whatever ;  yet,  according  to  my  expe- 
rience, except  in  such  slight  cases  as  were  merely  the  result  of  ordi- 
nary catarrh,  I  have  always  observed  the  membrana  tympani  in  the 
early  stage  of  the  afiection  showing  a  delicate  pink  tinge  upon  its  inner . 
surface — evidently  the  inflamed  mucous  layer  shining  through ;  and 
occasionally  presenting  a  posterior  mottled  opacity,  like  that  seen 
upon  the  back  of  the  cornea  in  aquo-capsulitis.  The  external  surface 
of  the  membrane  generally  preserves  its  polish,  and  it  is  only  as  a 
secondary  affection  that  its  middle  or  external  layers  become  thick- 
ened or  opaque,  which  they  generally  do  as  the  disease  passes  into  a 
chronic  stage.     When  we  get  the  membrana  tympani  fairly  within 


336  CATARKHAL    OTITIS. 

view,  with  a  clear  stream  of  sunlight  passing  down  to  it  through  a 
tubular  speculum,  and  then  desire  the  patient  to  force  the  air  into  the 
cavity  of  the  tympanum,  although  at  first  sight  we  may  not  be  able 
to  recognise  the  pink  tinge  to  which  I  have  alluded,  it  will  very  soon 
become  manifest,  as  the  blood  is  forced  into  the  structures  surround- 
ing the  tympanal  cavity.  This  tinge  must  not,  however,  be  confounded 
with  those  distinct  red  vessels  so  often  seen  upon  the  surface,  or 
between  the  laminae  of  the  membrane.  Mr.  T.  W.  Jones  says,  that 
"  accumulation  of  wax  in  the  auditory  passage,  and  muculent  obstruc- 
tion of  the  middle  ear,  occur  together"  occasionally;  I  have  not  ob- 
served this  symptom,  but  when  epidemic  catarrh  and  influenza  pre- 
vail, and  that  mucous  accumulations  are  common  in  the  tympanum,  I 
have,  as  already  mentioned,  frequently  remarked  an  increased  secre- 
tion of  thin,  pale-colored  cerumen  accompanying  such  afiections. 

Catarrhal  inflammation  of  the  middle  ear  sometimes  follows  an 
attack  of  bronchitis,  even  although  the  patient  may  not  have  been  ex- 
posed to  any  of  the  influences  likely  to  excite  aural  disease  at  the 
time.  "Mucocele  or  subacute  inflammation  of  the  mucous  lining  of  the 
lachrymal  sac,  with  accumulation  of  thin,  glairy  mucus,  like  white  of 
egg,  or  of  muco-purulent  matter,  or  even  pus,  forms  no  inapt  similitude 
to  the  afiection  of  the  ear  now  under  consideration ;  and  which,  like 
the  ophthalmic  disease,  is  often  induced  by  the  same  cause,  occurs  at 
the  same  period  of  life,  and  in  similar  constitutions,  requires,  in  many 
respects,  a  like  line  of  treatment,  both  local  and  general,  and  often 
terminates  in  the  same  manner, — the  mucous  accumulation  within  the 
tympanum  occasionally  ending  in  otitis,  with  ulceration  or  rupture  of 
the  membrana  tympani  and  discharge  of  its  contents  externally,  pre- 
cisely as  chronic  mucocele,^  with  partial  hernia  of  the  sac,  may  end  in 
acute  dacryocistis  and  fistula  lachrymalis.  In  the  progress  of  ca- 
tarrhal inflammation  of  the  middle  ear,  the  inspissated  mucus  accu- 
mulates, while  some  of  its  more  fluid  portion  passes  down  through  the 
Eustachian  tube ;  but,  even  supposing  the  latter  canal  to  be  obstructed 
by  stricture,  thickening  of  its  lining  membrane,  or  by  impaction  with 
mucus,  there  is  no  reason  to  suppose  that  the  semifluid  mass  contained 
within  the  tympanum  and  mastoid  cells  may  not  be  absorbed,  in  a 
healthy  constitution,  by  the  efibrts  of  nature,  or  by  judicious  un- 
mechanical  treatment.  That  such  occurs  daily,  and  with  just  as  much 
rapidity  as  it  had  been  secreted,  my  experience  of  this  disease  leads 
me  to  believe.  Take,  for  instance,  a  case  of  onyx,  in  which  pus  ac- 
cumulates in  the  anterior  chamber  of  the  eye,  so  as  almost,  if  not 


CHRONIC    INFLAMMATION    OE    THE    MIDDLE    EAR.       337 

altogether,  to  fill  it,  do  we  not  see  that  pus  under  judicious  treatment 
absorbed  in  an  incredibly  short  space  of  time  ?  Do  not  the  cavities 
of  the  pleura,  the  peritoneum  or  the  joints,  absorb,  as  well  as  pour  out, 
large  quantities  of  morbid  fluids  ?  Is  not  empyema  cured  by  absorp- 
tion daily  ?  Pending,  however,  the  process  of  absorption,  and  as  a 
consequence  of  the  original  catarrhal  inflammation,  the  extensive 
mucous  lining  of  the  middle  ear  must  become  thickened  and  villous, 
in  the  same  way  as  the  delicately  fine,  smooth,  polished,  transparent, 
and  intimately  adhering  conjunctiva,  lining  the  cartilage  of  the  upper 
eyelid,  becomes  villous  and  granular  in  the  progress  of  catarrhal 
ophthalmia. 

Chronic  inflammation  of  the  mucous  lining  of  the  middle  ear  and 
Eustachian  tube  follows  as  the  ordinary  consequence  of  the  foregoing 
disease ;  and  as  the  mucous  layer  of  the  membrana  tympani  becomes 
more  seriously  afiected,  the  other  laminae  of  that  structure  participate 
in  the  morbid  action,  and  thickening  and  opacity  follow.  Such  re- 
sults may  also  be  detected  by  examination,  assisted  by  the  history  of 
the  case,  and  by  Eustachian  catheterism  when  necessary  or  applicable, 
— we  can  also  well  imagine  the  amount  of  injury  that  must  be  inflicted 
upon  all  the  parts  covered  by  that  mucous  membrane,  and  in  joarticu- 
lar  the  mischief  done  to  the  fine  nervous  filaments  of  the  tympanic 
plexus  which  rainify  within  and  beneath  it.  The  two  following  cases 
are  fair  examples  of  this  disease. 

Chronic  inflammation  of  the  tympanum,  No.  1  in  Registry.  Janu- 
ary 24,  1850. — G.  S.,  a  male,  aged  20,  with  dark  complexion,  black 
hair,  and  brown  eyes ;  a  cook  on  board  one  of  the  Channel  steamers, 
and,  though  not  obliged  to  work  the  vessel,  very  much  exposed  to  the 
efiects  of  the  weather.  Has  been  partially  deaf  for  fom'teen  years. 
Was  treated  at  this  Institution  two  years  and  a  half  ago,  when,  he 
says,  his  hearing  was  restored. 

Right  ear. — Hearing  distance,  eight  inches.  Does  not  sufi'er  from 
pain  or  noise  on  either  side  ;  the  auricle  normal ;  the  meatus  natural 
in  form,  its  surface  smooth,  white,  and  polished,  but  totally  devoid  of 
wax.  This  suppression  of  the  natural  secretion  is,  however,  a  conse- 
quence of  the  inflamed  condition  in  which  the  external  auditory  pas- 
sage has  been  for  a  number  of  weeks,  months,  or  years.  Upon 
bringing  the  tympanal  membrane  into  view,  by  means  of  the  tubular 
speculum,  through  which  a  stream  of  clear  sunlight  is  transmitted,  it 
is  observed  to  be  of  a  mottled  red  and  white  character.  A  large 
grayish-white  spot  occupies  its  upper  and  posterior  margin ;  the  mem- 

22 


338  CHEONIC    OTITIS. 

brane  has  lost  its  polish,  is  rough  and  irregular  on  its  surface,  and  has 
become  thickened  throughout,  like  a  cornea  affected  with  dense  leu- 
coma:  and  the  position  of  the  manubrium  of  the  malleus  cannot  be 
distinguished  from  the  rest  of  the  drum-head.  By  holding  his  nose, 
keeping  his  mouth  shut,  and  making  a  forced  expiration,  the  patient 
is  unable  to  inflate  the  cavity  of  the  tympanum,  or  press  the  mem- 
brane outwards,  or  even  increase  and  give  greater  depth  to  the  color 
of  its  vascularity;  showing  not  only  that  the  air  does  not  pass  up 
freely  through  the  Eustachian  tube,  but  that  the  thickening  and  de- 
positions in  the  membrana  tympani  have  temporarily  obliterated  its 
vessels.  Upon  applying  the  naked  ear  or  the  otoscope  to  this  man's 
ear,  and  then  making  him  perform  the  experiment  which  has  been  just 
described,  we  do  not  hear  any  of  the  usual  sounds  observed  when  the 
air  gains  access  to  the  middle  ear.  He  had  for  a  long  time  a  muco- 
purulent discharge  from  this  ear,  but  of  this  he  was  relieved  on  his 
former  application. 

Left  Ear. — Hearing  distance,  six  inches.  Auricle  and  meatus  same 
as  on  right  side.  Tbe  characteristics  of  the  membrana  tympani  are 
also  somewhat  the  same,  but  on  this  side  there  is  a  greater  amount  of 
polish ;  there  is  a  half-ring  or  crescent  of  opacity,  situated  at  the 
upper  edge  of  the  membrane.  He  can  inflate  the  tympanum  on  this 
side,  raise  up  the  membrane  or  press  it  outwards,  and  render  it  more 
vascular, — proofs  that  the  Eustachian  tube  is  free.  He  had  formerly 
a  discharge  from  this  ear  also,  but  that  ceased  at  the  time  of  his 
former  attendance.  The  membrane  of  the  throat  is  natural.  The 
tonsils  are  not  enlarged.  The  end  of  the  uvula  was  removed  some 
years  ago. 

In  this  case  we  have  a  very  well-marked  example  of  inflammatory 
action  going  forward  in  the  tympanal  membrane,  and,  to  some  extent, 
in  the  membrane  lining  the  external  meatus  also,  the  symptoms  of 
which  are  observable  by  the  eye ;  and  we  may  fairly  infer  that  it  is 
not  confined  to  these  parts,  but  extends  along  the  mucous  lining  of 
the  middle  ear  down  through  the  Eustachian  tube,  in  the  same  way  as 
we  may  justly  pronounce  upon  the  extent  of  inflammation  throughout 
the  internal  structure  of  the  eye  in  cases  of  choroido-iritis,  or  general 
ophthalmitis. 

Treatment. — Counter-irritation  behind  the  ears  by  blisters,  applied 
as  frequently  as  possible ; — the  twelfth  of  a  grain  of  oxymuriate  of 
mercury  in  bark  taken  three  times  a  day. 

Eebruary  13th. — He  has  very  much  improved  since  last  examina- 


CHRONIC    OTITIS.  339 

tion.  Hears  at  fifteen  inches  on  right,  and  ten  on  left  side.  Two 
days  ago  he  heard  a  report  in  his  right  ear,  immediately  after  which 
his  hearing  improved,  owing  to  the  air  having  found  its  way  through 
the  Eustachian  tuhe,  the  previously  thickened  and  inflamed  mem- 
brane of  which  has  probably  resumed  its  natural  character ;  but  the 
hearing  has  varied  several  times  since,  as  the  passage  became  either 
blocked  up  by  mucus,  or  its  calibre  decreased  by  the  pulpy  infiltrated 
membrane.  Upon  bringing  the  right  tympanal  membrane  into  view 
to-day,  we  observe  that  it  is  of  a  mottled  pink  and  white  color ;  he 
still  cannot  inflate  it,  and  I  am  under  the  impression  that  it  would  be 
injurious  to  him  to  pass  a  catheter  into  the  Eustachian  tube,  as  some 
recommend,  and  through  it  force  a  quantity  of  cold  aii',  or  any  fluid, 
even  the  most  bland,  into  the  cavity  of  the  drum.  It  certainly  would 
cause  much  irritation,  and  possibly  increase  the  state  of  chronic  in- 
flammation we  are  laboring  to  subdue.  If  the  urethra  is  in  a  state 
of  inflammation  or  high  irritation,  or  a  man  has  an  inflamed  bladder, 
no  practical  surgeon  pushes  a  catheter  or  a  bougie  into  it.  As  the 
inflammation  subsides,  the  passage  wiU  open  without  any  mechanical 
means ;  the  air,  warmed  and  moistened  by  its  passage  through  the 
lungs,  or  over  the  surface  of  the  heated  mucous  membrane  of  the 
nose  and  mouth,  will  again,  as  it  did  a  few  days  ago  (perhaps  in  a  fit 
of  sneezing  or  coughing,  as  we  have  all  experienced  when  laboring 
under  a  catarrh),  gain  access  to  the  middle  ear ;  the  equilibrium  of 
the  tympanal  membrane  will  be  restored  and  hearing  improved. 

Left  Side. — The  membrana  tympani  is  still  slightly  pinkish,  but  its 
polish  is  much  improved,  and  there  is  a  scaliness  apparent  on  the  sm'face 
of  the  meatus,  which  is  always  a  promising  indication.  On  desiring 
the  patient  to  blow  into  his  ears,  as  already  described,  a  prolonged 
squeeHng  noise  is  heard  on  this  side,  showing  that  there  is  a  perfora- 
tion in  the  membrane,  which,  as  soon  as  it  takes  place,  always  im- 
proves the  hearing  in  cases  like  this.  The  opening  can  now  be  seen, 
not  larger  than  a  pin's  head,  with  a  valvular  edge,  which  flaps  up  and 
down  as  the  air  is  forced  through.  It  has  occurred  since  the  last 
examination,  about  four  days  ago,  and  is  situated  where  such  ruptures 
usually  take  place, — in  the  lower  and  somewhat  anterior  portion  of 
the  membrana  tympani,  nearly  opposite  the  opening  of  the  Eusta- 
chian tube.  A  little  thin  mucus  is  pressed  out  along  with  the  air 
through  the  opening.  The  aperture  was  touched  with  a  flne  camel's 
hair  pencil,  moistened  with  a  ten-grain  solution  of  the  nitrate  of  sil- 
ver.    Two  leeches  were  applied  to  the  meatus,  at  its  external  apertui'e, 


340  CHRONIC    OTITIS. 

and  the  counter-irritation  behind  and  below  the  insertion  of  the  auri- 
cle continued,  tartar  emetic  ointment  being  substituted  for  blisters, 
and  the  quantity  of  the  bichloride  of  mercury  and  bark  increased. 
His  general  health  has  much  improved, 

March  2d. — This  man  states  that  he  has  recovered  his  hearing ; 
that  it  is  even  better  than  it  was  prior  to  this  last  attack.  Upon 
examination,  the  tympanal  membranes  are  both  of  a  grayish-white 
color,  with  scarcely  any  vascularity  remaining.  The  aperture  upon 
the  left  side,  which  has  been  touched  with  a  caustic  solution  twice  a 
week  since  last  report,  has  completely  healed  up. 

No.  6  in  Registry. — Chronic  inflammation  of  both  middle  ears. 
Exploration  through  the  Eustachian  tubes. 

January,  1850. — J.  R.,  aged  20,  a  seaman,  has  been  deaf  for  some 
months  past,  and  attributes  his  affection  to  a  severe  cold,  caught  by 
falling  into  the  sea  from  the  deck  of  a  ship.  He  never  felt  pains  in 
his  ears  prior  to  that  time,  and  never  experienced  any  deafness 
before ;  says  he  did  not  become  deaf  suddenly,  but  that  his  hearing 
was  gradually  impaired  during  the  severe  attack  of  cold  under  which 
he  labored  at  the  time  referred  to ;  he  gives,  however,  a  very  con- 
fused account  of  his  symptoms,  or  the  history  of  his  case.  Seamen 
seem  to  be  particularly  liable  to  diseases  of  the  ear ;  but  from  their 
peculiar  habits  and  want  of  education,  they  are  bad  subjects  for 
examination.  It  Avill  scarcely  be  credited,  but  it  is  nevertheless  true, 
that  several  captains  of  merchantmen  and  colliers,  trading  to  this  port 
from  other  parts  of  the  United  Kingdom,  are  unable  to  write.  This 
man  says  his  deafness  came  on  from  cold,  and  possibly  such  was  the 
case.  Alterations  of  temperature,  sudden  or  long-continued  exposure 
to  the  effects  of  the  weather,  in  a  climate  so  variable  as  ours,  are 
some  of  the  most  frequent  causes  of  disease,  particularly  of  the  mu- 
cous membranes,  and  a  common  source  of  inflammation.  Hence, 
perhaps,  the  great  number  of  pulmonary  diseases,  the  deaths  from 
which  swell  the  Bills  of  Mortality  in  England  to  such  an  extent.  Yet 
one  of  the  most  common  excuses  made  by  deaf  persons,  upon  being 
asked  why  they  did  not  take  advice  sooner,  is,  "  Oh  !  I  did  not  think 
it  would  signify.  I  thought  it  was  only  a  cold,  particularly  as  I  had 
the  influenza  at  the  same  time."  Yes,  the  cause  was  in  all  proba- 
bility only  a  cold,  or  only  the  influenza,  and  both  are  very  likely  to 
accompany  or  be  attended  by  diseases  of  the  middle  ear.  During 
the  prevalence  of  influenza,  deafness  is  not  an  uncommon  symptom  ; 
the  relaxation  of,  and  over-secretion  from,  the  mucous  membrane  of 


CHRONIC     OTITIS.  341 

the  throat,  nose,  and  mouth,  extending  through  the  Eustachian  tube 
into  the  middle  ear. 

Right  Ear. — The  meatus  is  natural  in  appearance,  hut  remarkably 
long,  and  more  tortuous  than  usual.  The  membrana  tympani  seems, 
therefore,  to  be  deepen,  or  at  a  much  greater  distance  than  usual ;  it 
is  thickened,  opaque,  collapsed,  and  the  patient  has  not  the  power  of 
inflating  the  drum  and  pressing  the  membrane  outwards,  on  making  a 
forced  expiration.     He  cannot  hear  the  watch  on  this  side. 

Left  Ear. — Nearly  the  same  peculiarities  are  observed  as  in  the 
right.  The  membrana  tympani  is  both  thickened  and  opaque,  but  it 
still  bears  a  reddish  blush,  in  consequence  of  the  inflammatory  action 
yet  lingering  in  it.  He  hears  the  ticking  of  the  watch  upon  its  being 
pressed  against  this  ear,  but  is  not  conscious  of  any  sound  when  it  is 
placed  between  the  teeth,  or  laid  against  the  forehead.  There  is  a 
hissing  noise  m  both  ears,  and  he  states  that  he  is  occasionally  con- 
scious of  a  sudden  report,  as  if  a  small  pistol  was  fired  within  his  ear. 

As  the  tympanal  membranes  appear  collapsed,  and  as  the  patient 
is  unable  to  inflate  the  drum  on  either  side  by  any  efi'ort  upon  his 
part,  I  am  inclined  to  think  that  the  Eustachian  tubes  are  closed,  or 
the  cavities  of  the  middle  ear  blocked  up  with  mucous  secretion.^ 
The  acute  stage  having  already  passed,  and  some  months  having 
elapsed  since  the  original  inflammation  was  excited,  Eustachian  cathe- 
terism  was  therefore  resorted  to.  The  sound  heard  in  this  man's  ear 
was  of  a  gurgling  and  crackhng  character,  caused  by  the  stream  of 
air  rushing  through  the  mucous  secretion,  which  had  collected  in  the 
cavity  of  the  drum.  The  patient  himself  says,  he  feels  a  great  sound 
in  his  head,  as  if  a  trumpet  was  blowing  something  outwards  in 
his  ear. 

The  mucous  sound  at  first  heard  has  very  much  decreased,  and  has 
in  some  measure  given  place  to  the  ordinary  thug,  succeeded  by  the 
prolonged  vibratory  sound,  caused  by  the  stream  of  air  reaching  the 
membrana  tympani  without  interruption.  We  observe  that  it  raises 
up  that  part  which  is  most  vibratory,  and  placed  opposite  the  jet  of 
air,  and  also  that  it  at  the  same  time  renders  the  upper  and  posterior 
part  of  the  membrane  highly  vascular.  The  catheter  was  then  intro- 
duced upon  the  left  side,  and  nearly  the  same  phenomena  observed. 

The  patient  was  ordered  to  take  three  grains  of  chalk  and  mercury, 
with  one  of  extract  of  hemlock  three  times  a  day,  until  its  influence 

*  The  notes  of  these  cases,  it  must  be  remembered,  were  taken  from  clinical  lectures 
by  a  short-hand  writer. 


342  CHRONIC    OTITIS. 

upon  the  constitution  was  manifested.  Leeches  were  applied  to  the 
external  auditory  openings,  and  counter-irritation,  by  means  of  fre- 
quently repeated  blisters,  kept  up  behind  the  auricles. 

Feb.  13th. — The  mercury  acted  rather  briskly  upon  this  man,  but 
apparently  with  a  salutary  effect.  His  hearing  now  is  very  much 
improved ;  upon  the  right  side  he  can  hear  the  watch  at  an  inch  dis- 
tance, where  before  he  was  not  conscious  of  the  ticking,  even  when 
it  was  pressed  against  the  meatus ;  and  upon  the  left  side  he  hears  at 
two  inches.  Upon  both  sides,  the  external  auditory  passage  is  dry 
and  scaly,  as  if  covered  over  with  an  herpetic  eruption, — a  very  com- 
mon appearance  in  this  locality  upon  the  subsidence  of  an  inflamma- 
tory attack.  The  tympanal  membrane  is  still  pinkish  upon  both 
sides ;  but  it  appears  somewhat  less  dense  and  white  since  the  time 
when  first  examined.  The  singing  noise  still  remains,  but  is  not  so 
distressing.  This  patient  stated,  that  he  had  to  go  to  sea  next  day ; 
and  he  has  not  been  seen  at  the  Institution  since. 

As  a  consequence  of  either  catarrhal  or  chronic  inflammation  of 
the  middle  ear,  thickening  of  the  mucous  membrane,  contraction  in 
the  calibre  of  the  Eustachian  tube,  or  an  accumulation  of  inspissated 
mucus  in  the  tympanum,  may  result.  For  the  relief  of  these  morbid 
changes,  catheterism  of  the  Eustachian  tube,  and  the  forcible  injection 
of  a  stream  of  medicated  air  or  water,  have  been  recommended,  and 
are  by  some  persons  extensively  practised ;  but,  should  these  means 
prove  ineffectual,  we  are  told  in  books,  as  already  alluded  to  at  page 
82,  to  introduce  a  catgut  bougie  through  the  Eustachian  tube  into 
the  middle  ear,  in  order  to  break  up  the  plug  of  inspissated  mucus. 
It  is  scarcely  necessary,  in  the  present  state  of  medicine,  to  criticise 
this  most  unjustifiable  practice.  With  respect  to  gaseous  or  aeriform 
injections,  they  are,  to  say  the  least  of  them,  generally  innocuous, 
and  may  sometimes  prove  beneficial,  not  merely  as  diagnostics,  but 
by  giving  a  healthy  action  to  the  mucous  surface.  It  is  in  this  way 
that  I  believe  the  medicated  air-douche  acts  in  certain  forms  of 
disease  of  the  ears,  erroneously  described  as  "nervous  deafness,"  not 
by  stimulating  the  proper  nerve  of  hearing,  which  it  cannot  reach, — 
and  even  if  it  could,  we  have  no  warrant  or  analogy  to  lead  us  to 
suppose  that  it  could  effect  any  such  influence, — but  by  improving 
the  condition  of  the  mucous  lining  of  the  tympanal  cavity.  It  is  also 
in  this  way  that  I  believe  the  use  of  tobacco-smoke,  already  described 
at  page  252,  proves  efficacious,  especially  in  cases  complicated  with 
relaxation  and  some  chronic  thickening  of  the  mucous  membrane  of 


CHRONIC    OTITIS.  343 

the  throat.  When  the  mucous  rale  remains  after  the  ordinary  means 
for  subduing  inflammation  and  improving  the  general  health  have 
been  resorted  to,  and  that  the  air-douche  has  proved  ineffectual  in 
removing  mucous  accumulation  in  the  middle  ear,  it  has  been  recom- 
mended in  books,  and  is  still  practised  by  aurists,  to  wash  out  the 
tympanum  with  injections  of  warm  water,  by  means  of  a  conamon 
syringe  fitted  to  the  Eustachian  catheter  held  in  the  nose  by  the 
patient  or  the  operator.  I  have  a  doubt  as  to  whether  such  fluids  so 
applied  ever  reach  the  tympanic  cavity  in  the  majority  of  instances 
where  they  are  used  ;  but  I  have  no  doubt  that,  in  a  large  majority  of 
cases  of  catarrhal  or  chronic  inflammation  of  the  middle  ear,  mecha- 
nical interference  is  highly  objectionable.  How,  then,  are  we  to 
treat  this  insidious,  frequent,  and  most  injurious  affection  ?  A  recent 
author  says,  "  venesection  is  too  frequently  neglected  in  this  affec- 
tion!" but  I  do  not  think  any  judicious  surgeon  in  the  present  day 
will  take  out  his  lancet  and  open  a  vein  at  the  bend  of  the  elbow  when 
applied  to  by  a  patient  seeking  relief  for  catarrhal  or  chronic  inflam- 
mation of  the  middle  ear,  no  more  than  he  would  for  ordinary  catarrh 
or  influenza,  chronic  ophthalmia,  or  any  similar  painless  disease  in 
which  the  strength  of  the  patient  requires  support,  and  the  general 
condition  of  the  constitution  indicates  the  use  of  tonics.  Slight  local 
depletion,  repeated  from  day  to  day,  by  means  of  a  few  leeches  ap- 
phed  on  the  external  meatus  in  the  early  stage  of  the  disease,  the  use 
of  counter-irritation,  by  means  of  blisters,  over  the  mastoid  process, 
and  subsequently  painting  that  part  with  strong  tincture  of  iodine ; 
the  use  of  astringent  gargles,  particularly  of  the  preparations  of  alum, 
so  long  as  the  throat  exhibits  symptoms  of  disease,  will  be  found  most 
efficacious.  I  believe  the  act  of  gargling  is  in  itself  highly  beneficial, 
I  presume  by  the  way  in  which  it  acts,  through  the  muscles  of  the 
pharynx  and  palate,  upon  the  Eustachian  tube.  The  application  of 
a  strong  solution  of  nitrate  of  silver  to  the  throat,  as  described  at 
page  263,  every  second  or  third  day,  considerably  assists  in  the  treat- 
ment. I  am  inclined  to  think  that  its  action  is  not  confined  to  the 
part  to  which  it  is  applied,  but  that  it  exercises  a  beneficial  influence 
upon  remote  portions  of  the  same  structure,  even  the  mucous  lining 
of  the  middle  ear.  There  is  generally  derangement  of  the  digestive 
organs  accompanying  these  affections  :  the  tongue  is  usually  flabby, 
white,  and  its  edge  indented  with  the  teeth ;  the  bowels  are  irregular ; 
the  patient  complains  of  acid  eructations  in  the  morning ;  the  face  is 
pale,  the  skin  cold,  the  spirits  depressed,  and  the  patient  altogether 


344  DISEASES    OF    THE    MASTOID    PROCESS. 

in  that  condition  denominated  "  dyspeptic."  This  is,  I  presume,  the 
form  of  disease  described  by  some  writers  as  "  stomach  deafness ;" 
and  in  such  cases  the  state  of  the  digestive  organs  demands  attention : 
but  if  we  confine  our  treatment  to  the  removal  of  the  dyspeptic  symp- 
toms, without  employing  such  local  means  as  I  have  described,  we 
shall  be  allowing  valuable  time  to  pass  by,  and  when  we  have  ex- 
hausted an  extensive  range  of  treatment  in  "setting  the  stomach  to 
rights,"  we  shall  find  the  aural  disease  no  better  than  when  we  began. 
In  other  cases  the  general  health  appears  to  be  unimpaired. 

The  general  treatment,  consisting  chiefly  of  gentle  alteratives  and 
tonics,  such  as  I  have  recommended  in  cases  of  subacute  and  stru- 
mous myringitis,  referred  to  at  the  commencement  of  this  section,  are 
equally  applicable  in  the  present  case.  In  some  females  the  muriated 
tincture  of  iron,  given  in  combination  with  the  bichloride  of  mercury, 
is  more  beneficial  than  in  any  other  form  of  aural  disease,  I  have 
not  found  the  hydriodate  of  potash  as  useful  in  this  disease  as  when 
the  fibrous  structures  of  the  ear  are  aifected.  It  is,  upon  the  whole, 
an  uncertain  remedy;  and,  although  it  occasionally  makes  what  is 
called  "a  hit,"  it  very  frequently  disagrees  with  the  stomach;  and, 
by  producing  iodization,  it  rather  increases  the  relaxation  and  humi- 
dity of  the  mucous  surface,  which  it  is  intended  to  benefit.  In  chil- 
dren and  young  persons,  the  iodide  of  iron,  given  in  the  form  of  syrup, 
is  generally  beneficial,  and  may  be  continued  for  a  long  time.  Where 
aperients  are  acquired,  small  doses  of  blue-pill,  the  watery  extract  of 
aloes,  and  taraxacum,  will  be  found  a  useful  combination.  A  dry, 
warm  atmosphere  is  not  only  most  agreeable  to  the  patient's  feelings, 
but  materially  improves  the  condition  of  the  ear.  When  the  mem- 
brana  tympani  exhibits  evidence  of  thickening  or  opacity,  it  should 
be  treated  with  nitrate  of  silver,  as  I  have  already  explained. 

DISEASES    OF    THE    MASTOID    PROCESS    AND    OSSICULA. 

As  the  otitis,  from  whatever  cause  it  may  have  arisen,  increases  in 
intensity,  or  extends  in  duration,  the  neighboring  parts  become 
affected ;  periosteal  inflammation  denudes  the  margin  of  the  auditory 
process,  spreads  over  the  surface  of  the  mastoid  region,  and  caries 
and  exfoliation  of  the  mastoid  process  not  unfrequently  follow  at 
some  period,  more  or  less  remote,  but  generally  during  the  progress 
of  the  subsequent  otorrhoea.  When  periostitis  of  the  mastoid  process 
can  be  detected,  it  should  be  treated  with  promptness,  as  I  have 
already  directed  at  page  233. 


DISEASES    OP    THE     OSSICULA.  345 

Whetlier  inflammation  of  the  mastoid  cells  ever  exists  as  an  idio- 
pathic affection,  and  not  by  extension  of  morbid  action  from  the 
cavity  of  the  tympanum,  I  cannot  say,  never  having  myself  met  with 
such  a  case ;  but  that  they  become  secondarily  affected  is  well  known. 
Fine  and  delicate  as  the  membrane  lining  these  cells  is  in  a  state  of 
health,  I  have  seen  it,  in  cases  of  chronic  disease,  of  a  livid  red, 
thickened,  and  even  so  pulpy  as  completely  to  fill  up  the  smaller  com- 
partments, and  to  bulge  out  of  the  cells  on  making  a  section  of  the 
mastoid  process.  Such  is  precisely  the  appearance  in  a  dissection 
now  lying  before  me,  and  the  history  of  which  will  be  found  in  the 
chapter  on  otorrhoea.  The  mastoid  cells  have  likewise  been  found 
filled  with  cheesy  deposit,  also  with  quantities  of  scrofulous  matter, 
and  with  true  tuberculous  deposit.  The  whole  process  has  been  found 
so  soft,  that  it  could  be  cut  with  a  knife.  Fistulous  communications, 
opening  from  the  mastoid  cells  externally,  are  by  no  means  uncom- 
mon in  neglected  cases  of  otorrhoea ;  and  exfoliation  of  a  thin  scale  of 
bone,  immediately  behind  the  attachment  of  the  auricle,  often  follows 
acute  otitis,  especially  in  those  cases  in  which  a  free  incision  having 
been  made  to  relieve  the  inflamed  periosteum,  the  progress  of  the 
disease  has  been  checked.  In  neglected  cases,  particularly  in  young 
children,  the  whole  mastoid  process  not  unfrequently  comes  away. 

Artificial  perforation  of  the  mastoid  process,  for  the  purpose  of 
throwing  injections  into  the  middle  ear,  or  to  relieve  deafness  in  cases 
where  the  Eustachian  tube  has  been  completely  closed,  an  operation 
to  which  I  have  already  adverted  at  page  33,  has  long  since  been 
exploded,  not  only  as  ineffectual,  but  positively  hazardous. 

Diseases  of  the  ossicula  are,  I  believe,  much  more  frequent  than 
sui'geons  are  aware  of;  we  have,  however,  acquired  but  little  know- 
ledge on  the  subject,  except  that  derived  from  dissection,  or  in  cases 
of  otorrhoea  attended  with  destruction  of  the  membrana  tympani,  in 
which  some  of  these  ear-bones  have  been  discharged.  They  are 
liable  to  all  the  affections  to  which  bone  is  subject — ulceration,  ab- 
sorption, caries,  and  anchylosis,  as  already  described  at  page  117. 
Anchylosis  of  the  stapes  is  said  to  be  of  common  occurrence.  They 
may  be  also  dislocated  one  from  another,  or  totally  disconnected,  and 
they  have  been  found  within  the  mastoid  cells,  or  even  in  the  vesti- 
bule. Injuries  of  the  tympanal  cavity  must  affect  these  little  bones 
just  as  seriously  as  the  same  amount  of  violence  done  to  any  of  the 
other  bones  or  joints  of  the  human  body. 

Morbid  growths  and  deposits  of  various  kinds  have  been  discovered 


346  MALIGNANT    FUNGUS. 

in  the  cavity  of  the  tymjjanum.  When  in  a  state  of  clironic  inflam- 
mation, and  exposed  to  the  action  of  the  air,  as  in  cases  of  otorrhoea 
with  perforation  or  destruction  of  the  membrana  tympani ;  the  mucous 
lining  is  always  thickened,  highly  vascular,  and  pulpy,  not  inaptly 
resembling  the  surface  of  a  well-injected  fetal  stomach ;  and  we  must 
suppose,  that  it  presents  in  a  modified  form  something  of  the  same 
condition  in  cases  of  otitis,  or  in  those  catarrhal  affections  attended 
with  muculent  accumulation.  Unhealthy  granulations  and  polypoid 
growths  spring  from  it,  but  not  so  frequently  as  from  the  external 
meatus.  Exostosis  has  been  noticed  by  observers,  of  which  I  have 
given  an  instance  at  page  205 ;  but,  independent  of  such  isolated 
bony  growths,  the  whole  osseous  walls  of  the  tympanum  have  been 
found  upon  dissection  thickened,  and  when  caries  has  affected  them, 
large  portions  have  been  thrown  off  by  exfoliation.  In  fact,  when 
once  disease  seizes  upon  the  parietes  of  the  middle  ear,  it  is  impossi- 
ble to  say  what  amount  of  mischief  it  may  not  effect. 

MALIGNANT   FUNGUS. 

In  the  section  devoted  to  diseases  of  the  external  meatus,  I  gave 
the  history  of  two  cases  of  malignant  disease  of  the  ears,  both  of 
which  ended  in  a  remarkably  short  space  of  time.  The  following 
case  was  of  a  more  chronic  nature,  although  it  eventually  proved 
equally  fatal  with  the  two  former,  related  at  pages  205  and  207 ;  and 
I  have  placed  it  among  diseases  of  the  middle  ear,  because  it  did  not, 
like  them,  appear  to  commence  by  a  polypous  groAvth  in  the  meatus, 
but  sprouted  from  the  mastoid  process  directly.  The  gentleman  who 
was  the  subject  of  this  frightful  disease  was  a  native  of  Scotland,  and, 
when  I  saw  him,  a  fetid  fungous  mass  occupied  the  entire  of  the 
mastoid  or  post-aural  region,  which  was  considerably  enlarged,  par- 
ticularly from  before  backwards.  Large  portions  of  it  occasionally 
sloughed,  especially  at  the  inferior  part,  and  considerable  hemorrhage 
ensued  on  each  occasion.  The  auricle  was  elongated,  and  dragged 
downwards  by  the  fungous  mass,  a  portion  of  which  protruded  through 
the  external  meatus ;  there  was  complete  paralysis  of  the  parts  sup- 
plied by  the  facial  nerve  on  the  right  side.  The  patient,  a  man  about 
55,  stated  that  he  had  suffered  from  otorrhoea  for  several  years  pre- 
viously ;  that  the  present  disease  was  of  nine  or  ten  months'  duration ; 
and  that  the  tumor  first  appeared  behind  his  ear.  He  also  said  that 
he  had  had  it  twice  removed  by  a  surgeon  in  Glasgow,  and  that  he 


DISEASES    OF    THE    EUSTACHIAN    TUBE.  847 

had  lately  consulted  Professor  Syme,  ttIio  most  wisely  advised  him 
not  to  allow  it  to  be  interfered  with  further.  When  he  consulted  me 
he  was  suffering  from  violent  pain  in  the  head,  and  vertigo,  and  was 
greatly  emaciated,  so  that  I  suppose  his  sufferings  did  not  last  much 
longer.     He  returned  to  Scotland  a  few  days  after  I  saw  him. 

DISEASES    or   THE   EUSTACHIAN   TUBE. 

Were  we  to  put  implicit  faith  in  the  writings  of  authors,  or  to 
quote  authorities  upon  diseases  of  the  Eustachian  tube,  we  should  be 
led  to  believe  that  the  affections  of  that  portion  of  the  middle  ear  are 
of  common  occurrence ;  with,  however,  the  exception  of  subacute 
inflammation,  thickening  of  the  mucous  membrane,  and  consequent 
closure,  more  or  less  complete,  temporary,  or  permanent,  of  the  tym- 
pano-faucial  canal,  as  described  in  several  of  the  foregoing  portions 
of  this  work, — I  think  that  disease  of  that  portion  of  the  auditory 
apparatus  is  neither  itself  frequent  nor  a  usual  cause  of  deafness, 
rurthermore,  it  remains  to  be  proved,  that  an  impervious  condition 
of  this  canal  is,  as  generally  supposed,  a  cause  of  deafness.  Every 
form  of  inflammation  of  the  mucous  membrane  of  the  throat  may, 
and  often  does,  by  continuity  of  surface,  extend  into  the  Eustachian 
tube ;  and,  as  I  have  already  stated,  it  is  through  it  that  that  most 
severe  form  of  otitis,  derived  from  scarlatina,  extends  into  the  tym- 
panic cavity ;  but  this  is  no  new  doctrine,  it  was  known  to  Hippo- 
crates, who  said  that,  in  quinsy  of  the  fauces,  the  patient  became 
deaf  by  closure  of  the  Eustachian  tube.  That,  however,  the  most 
extensive  throat  disease  may  not  affect  the  Eustachian  canal,  or  in 
any  way  impair  hearing,  I  have  an  instance  at  this  moment  before  me, 
in  which  a  gentleman,  under  treatment  for  another  affection,  presents 
the  peculiarity  of  complete  occlusion  of  the  naso-pharyngeal  opening, 
owing  to  adhesion  of  the  velum  palati  to  the  back  and  sides  of  the 
pharynx,  the  result  of  syphilitic  ulceration.  There  is  no  vestige  of 
uvula  remaining,  and  examination  with  a  small  mirror  does  not  show 
any  aperture  whatever  throughout  the  whole  length  of  the  cicatrix. 
The  patient's  hearing  is  most  acute. 

Syringitis,  or  inflammation  of  the  Eustachian  tube,  may  exist  as 
an  isolated  affection ;  but  I  know  no  symptoms,  except  those  detailed 
at  page  334,  and  ^hich  are  common  to  it  and  catarrhal  otitis,  by 
which  it  may  be  recognised.  In  all  cases  of  aural  disease  the  con- 
dition of  the  Eustachian  tube,  so  far  as  permeability  is  concerned, 


348  DISEASES    OF    THE    EUSTACHIAN    TUBE. 

should  be  tested  bj  the  means  pointed  out  at  page  74.  Yet,  it  must 
be  borne  in  mind,  that  many  persons  possess  good  hearing  ^Yho  are 
not  able  to  press  air  into  the  tympanum  by  holding  the  nose  between 
the  finger  and  thumb,  keeping  the  mouth  shut,  and  then  making  a 
forced  exjDiration  ;  and  many  persons  there  are  who  can  only  occasion- 
ally, and  that  with  difficulty,  force  air  through  the  Eustachian  tube  on 
one  side  ;  yet  they  can  hear  equally  well  on  both  sides.  If  the  patient 
cannot  inflate  the  drum  by  this  means,  we  should  resort  to  the  use  of 
the  catheter  and  air-douche,  as  already  described  at  page  75.  Should 
the  operation  fail,  and  that  the  surgeon  is  'perfectly  sure  that  the 
deafness  arises  from  occlusion  of  the  Eustachian  tube,  by  inspissated 
mucus  or  stricture,  and  that  the  membrana  tympani  and  middle  ear 
are  free  from  disease,  he  may,  having  previously  introduced  the 
catheter  into  the  guttural  orifice  of  the  tube,  carefully  and  cautiously 
pass  a  fine,  flexible  bougie  through  it  into  the  remaining  portion  of 
the  canal  up  to,  but,  if  possible,  not  into,  the  tympanal  cavity. 
Whalebone  stilettos  and  catgut  bougies  have  been  recommended  as 
the  best'means  for  effecting  this  end ;  but,  as  I  have  already  stated 
at  page  83,  the  only  instrument  which  I  ever  pass  through  the  Eusta- 
chian tube  is  a  fine  ivory  bougie,  from  which  the  earthy  portion  has 
been  removed  by  means  of  an  acid,  and  the  end  of  which,  when  pre- 
viously moistened  for  some  time,  becomes  soft  and  pliable,  yet  pos- 
sesses more  resistance  than  catgut.  In  many  cases  of  puriform 
discharge  from  the  ear,  in  which  the  greater  portion  of  the  mem- 
brana tympani  had  been  removed,  I  have  noticed  that  the  Eustachian 
tube  was  not  free ;  and  Saunders  observed  the  same,  and  relates  a 
case  in  which,  upon  dissection,  the  canal  was  found  impervious.  In 
such  instances,  I  presume  that  the  occlusion  occm-red  either  at  the 
time  of  the  original  otitis  which  produced  the  otorrhoea,  or  subse- 
quently, by  extension  of  the  chronic  inflammation  and  hypertrophy 
of  the  mucous  membrane  to  that  lining  the  Eustachian  canal.  Stric- 
ture of  the  Eustachian  tube  is  not  only  exceedingly  rare,  but,  says 
Mr.  T.  W.  Jones,  "  when  it  exists,  is  in  no  case  the  sole  cause  of  the 
deafness ;  and  it  would  be  of  no  use  to  subject  the  patient  to  the 
distress  attending  attempts  at  dilatation,  even  if  success  in  the  object 
could  be  calculated  on.  It  is  sometimes  found,  as  already  mentioned, 
that  it  is  in  the  duller  ear  the  Eustachian  tube  is  pervious !  and  that, 
when  impervious  Eustachian  tubes  are  rendered  free,  so  that  the 
access  of  air  to  the  tympanic  cavities  is  again  permitted,  this  is  not 
always  followed  by  any  amelioration  of  the  deafness." 


DISEASES    OF    THE    EUSTACHIAN    TUBE.  '349 

I  would  refer  those  who  may  desire  to  be  acquainted  with  the  lite- 
rature of  Eustachian  diseases,  to  Lincke's  work,  in  which  he  has 
described,  besides  inflammation  of  the  lining  of  the  canal,  dilatation, 
stricture,  obstruction,  collapse,  obliteration,  and  imperforation  of  that 
portion  of  the  auditory  apparatus. 

We  have  not  on  record  a  suflScient  number  of  post  mortem  exami- 
nations of  the  Eustachian  tube  throughout  the  whole  extent  of  that 
canal,  to  be  able  to  speak  with  any  degree  of  certainty  as  to  the  pro- 
portion of  cases  in  which  stricture  or  other  morbid  appearances  pre- 
sent. It  has,  however,  been  found  impacted  with  mucus,  its  lining 
membrane  thickened,  crossed  by  bands  of  adhesion ;  the  sides  of  its 
guttural  orifice  adherent,  apparently  from  ulcerations,  and  a  large 
portion  of  the  canal  occluded;  but  strictures,  such  as  those  which 
occur  in  the  male  urethra,  have  not  been  described.  One  of  the  most 
recent  dissections  of  this  part  in  which  disease  was  discovered,  is  that 
by  Mr.  Toynbee,  in  the  case  of  a  person  aged  45,  who  died  of  phthisis. 
"Twenty  years  previously  he  sufi"ered  from  otitis,  which  ended  in  con- 
firmed otorrhoea  in  the  right  ear ;  and,  when  examined  a  few  days 
before  his  death,  it  was  observed  that  the  membrana  tympani  on  that 
•side  was  absent,  and  the  lining  of  the  tympanic  cavity  presented  the 
thickened  condition  usual  in  such  cases.  Upon  the  left  side,  in  which 
the  patient  had  suffered  from  painless  deafness  for  some  years,  the 
membrana  tympani  was  as  white  as  writing-paper,  and  partially  dull 
upon  its  surface.  The  condition  of  the  Eustachian  tube  was  not  in- 
quired into,  the  patient  being  in  a  debilitated  state.  Upon  inspection 
after  death,  the  tympanic  cavity  and  mastoid  cells  upon  the  left  side 
were  found  filled  with  mucus;  the  state  of  the  Eustachian  tube  is 
given  as  follows:^ — "The  internal  portion,  for  the  length  of  half  an 
inch,  was  healthy ;  but,  at  about  that  distance  from  the  cavity  of  the 
tympanum,  there  was  a  sudden  constriction,  and  for  the  length  of 
about  a  line  and  a  half,  the  tube  was  so  contracted  that,  even  when 
its  anterior  wall  was  removed,  it  was  with  difficulty  that  an  ordinary- 
sized  bristle  could  be  introduced  into  the  opening.  The  stricture  re- 
sulted from  the  external  and  internal  walls  of  the  tube  pressing  against 
each  other,  the  small  space  still  permeable  being  above  the  upper 
part.  The  most  remote  cause  of  the  stricture,  however,  would  ap- 
pear to  have  been  an  enlargement  of  portions  of  the  bone  constituting 
the  external  and  internal  osseous  walls  of  the  tube.     The  external 

'  See  Monthly  Journal  of  Medical  Science  for  August,  1850.     The  wood-cut  attached 
to  the  description  of  the  case  referred  to  is  not  sufficiently  distinct. 


350  DISEASES    OF    THE    EUSTACHIAN    TUBE. 

osseous  wall  was  at  this  part  twice  its  natural  thickness,  and  some- 
what rough  ;  while  the  internal  wall  was  forced  outwards  by  the 
dilatation  of  the  carotid  canal,  which,  thus  pressing  upon  the  cartila- 
ginous portion  of  the  Eustachian  tube,  with  which  it  was  in  contact, 
produced  a  flattening  of  the  natural  concavity  of  the  internal  wall. 
The  mucous  membrane  lining  the  Eustachian  tube  was  in  a  natural 
state."  The  author  states  that  "the  existence  of  this  stricture  would 
have  been  detected  during  life  had  the  Eustachian  catheter  and  oto- 
scope been  resorted  to;"  but  that  strong  presumptive  evidence  of  its 
existence  might  be  afforded  by  the  peculiar  opacity  of  the  membrana 
tympani,  for  that,  with  the  exception  of  mucous  accumulations, 
arising  from  thickening  of  the  mucous  lining  of  the  tympanic  cavity, 
he  "did  not  know  of  any  disease  which  produces  the  peculiar  white- 
ness in  the  membrana  tympani."  Notwithstanding  his  usual  perspi- 
cuity, the  author  has  not  mentioned,  with  the  exception  of  the  opacity 
of  the  membrana  tympani,  by  what  method  of  diagnosis  the  stricture 
would  have  been  discovered,  or  how  distinguished  from  ordinary- 
temporal^  occlusion,  arising  from  thickening  of  its  mucous  lining,  or 
complete  stoppage,  by  means  of  a  piece  of  inspissated  mucus,  and  the 
white  papery  appearance  of  the  membrana  tympani  is  common  to 
nearly  all  cases  in  which  inflammation  attacks  any  of  its  layers,  or 
morbid  deposits  occur  within  or  upon  it.  In  such  a  case  as  the  fore- 
going, the  only  hope  of  amendment  would  be  from  perforation  of  the 
membrana  tympani,  as  detailed  at  page  283. 

Of  the  history  of  Eustachian  catheterism,  and  the  part  which 
British  surgeons  have  taken  in  the  progress  of  that  operation,  I  have 
already  spoken  fully  in  the  introductory  chapter  of  this  work.  The 
rather  novel  doctrine  of  the  Eustachian  tube  remaining  closed,  except 
during  the  act  of  deglutition,  has  lately  been  propounded  by  Mr. 
Toynbee. 

Foreign  bodies  have  been  found  in  the  Eustachian  tube ; — the  most 
remarkable  case  on  record  is  that  in  which  an  ear  of  barley  was  dis- 
covered after  death  projecting  from  its  guttural  orifice. 

Cleft  palate  may,  it  is  said,  produce  deafness,  owing  to  the  partial 
closure  of  the  Eustachian  tube  from  the  side  of  the  divided  soft  palate 
lying  up  against  it ;  and  not  a  little,  I  should  think,  from  the  defi- 
ciency of  resistance  in  the  inferior  attachment  of  the  levator  palati 
muscle,  allowing  the  lower  portion  of  the  walls  of  the  Eustachian  tube 
to  fall  together.  I  lately  examined  two  cases  of  cleft  palate  in  young 
females:  in  both  instances  the  fissure  extended  anteriorly  into  the 


THROAT    DEAFNESS.  351 

hard  palate ;  both  were  partially  deaf.  In  the  case  in  which  there 
was  most  hardness  of  hearing,  the  membrana  tympani,  on  both  sides, 
was  thickened,  opaque,  and  partially  vascular,  and  the  patient  suf- 
fered occasional  pain  in  the  ears,  increased  on  catching  cold ;  and  she 
had  also  tinnitus  aurium.  In  the  other  case,  in  which  the  patient 
was  least  deaf,  there  was  no  disease  apparent  in  the  parts  submitted 
to  inspection. 

THROAT   DEAFNESS. 

Of  deafness  arising  from  disease  of  the  throat,  or  said  to  be  caused 
by  enlarged  tonsils,  or  elongated  uvula,  I  have  already  expressed  my 
opinion  (see  pp.  46,  48).  The  profession  may,  however,  be  told,  that 
neither  anatomy,  physiology,  pathology,  nor  even  reason  and  common 
sense,  can  stand  in  competition  with  facts.  Now,  here  is  a  fact  sup- 
plied by  Mr.  Yearsley,  the  great  supporter  of  the  tonsillitic  form  of 
deafness : — 

"  Enlarged  tonsils  producing  deafiiess  and  thick  speech. — An  emi- 
nent physician  intrusted  his  son  to  my  care.  The  hearing  was 
extremely  imperfect,  the  voice  thick  and  nasal,  and  the  articulation 
so  indistinct  as  to  be  almost  unintelligible  to  strangers.  The  tonsils 
were  permanently  enlarged,  and  the  mucous  membrane  generally  was 
in  a  state  of  chronic  inflammation.  The  most  approved  mechanical 
and  topical  treatment  had  failed  in  affording  relief.  The  protruding 
portion  of  the  left  tonsil  was  excised,  after  which  every  symptom 
gradually  subsided." 

In  that  case  the  negative  certainly  counterbalanced  the  positive 
signs. 

In  reply  to  Mr.  Yearsley's  doctrine,  Mr.  Harvey,  in  his  book  on 
the  subject  referred  to  in  page  48,  states,  that  "  extirpation  of  the 
tonsil  in  the  young  has  led  to  pernicious  results, — such  as  giving  rise 
to  bronchial  and  pulmonary  disease,  with  other  mischiefs  to  be  men- 
tioned in  this  work ;  and,  notwithstanding  high  authorities  in  favor 
of  extirpating  the  tonsils  or  uvula,  for  the  relief  of  deafness,  the 
operation  has  almost  uniformly  proved  a  failure." 

But,  without  bandying  opinions  or  citing  authorities  on  this  sub- 
ject, I  appeal  to  every  practical  physician  and  surgeon,  as  to  whether 
patients  with  chronic  enlargement  of  the  tonsils  are  more  prone  to 
deafness  than  other  persons  with  similar  constitutional  tendencies. 

Wishing  to  investigate  the  subject  on  a  large  scale,  I  lately  applied 


352  THKOAT     DEAFNESS. 

to  Drs.  Mayne  and  Kirkpatrick,  physicians  to  tlie  Dublin  Workhouses, 
for  an  opportunity  of  examining  the  tonsils  of  any  cases  which  might 
offer  among  the  numerous  children  and  young  persons  under  their 
care ;  and  they  have  informed  me,  that  chronic  enlargement  of  the 
tonsils  is  almost  unknown  among  the  pauper  poor  and  the  lower 
orders :  and  they  attribute  the  enlargement  of  these  glands,  seen  in 
the  middle  and  upper  ranks  of  life,  to  high  feeding. 

Polypus  of  the  nose  does  not  cause  deafness  when  of  the  ordinary 
gelatinous  kind ;  but  I  have  seen  deafness  induced  by  a  large  fleshy 
polypus  which  passed  down  into  the  pharynx. 


353 


CHAPTER   VIL 

DISEASES   OF   THE   INTERNAL   EAR. 

Anatomy  of  the  Osseous  Labyrinth. — The  Cochlea,  Vestibule,  and  Semicircular  Canals. 
— The  Membranous  Labyrinth. — The  Seventh  Pair  of  Nerves. — The  Auditory  Nerve.' — • 
Congenital  Malformations  of  the  Internal  Ear. — Wounds  and  Injuries. — Inflammations: 
Internal  Otitis;  Otorrhcea — Caries. — Malignant  Growths. — Tinnitus. — Otalgia. — Hyper- 
cusis. — Nervous  Deafness :  Its  Diagnosis,  Symptoms,  and  Treatment. — The  Opinions  of 
Kramer  and  Schmalz. — The  Medicated  Air-Douche. — The  Ether  Cure. 

The  middle  ear  or  labyrinth  contains  the  ear-bulb  or  true  sentient 
apparatus  of  hearing,  to  which  all  the  other  portions  are  accessory. 
The  osseous  labyrinth  is  situated  in  the  petrous  portion  of  the  tem- 
poral bone,  near  its  cerebral  surface,  and  between  the  meatus  audito- 
rius  internus,  for  the  transmission  of  the  auditory  nerve  and  the 
internal  wall  of  the  tympanic  cavity,  with  which  space  it  communicates 
by  the  round  and  oval  apertures  already  described  under  the  head  of 
the  Anatomy  of  the  Cavitas  Tympani.  This  bony  case,  in  which 
the  membranous  labyrinth  and  the  terminal  expansion  of  the  auditory 
nerve,  with  its  surrounding  fluid,  is  situated,  is  divided  into  three 
compartments,  distinguished  as  the  cochlea,  the  semicircular  canals, 
and  the  vestibule.  This  latter  space  communicates  with  the  two 
former,  and  also  with  the  tympanum  through  the  foramen  ovalis, 
which,  in  the  recent  state,  is  closed  by  the  end  of  the  stapes  and  its 
surrounding  membrane  and  hgaments.  For  wise  purposes  in  the 
animal  economy,  this  osseous  labyrinth  is  curiously  fashioned  out  of 
the  densely  hard,  solid  bone,  and  can  only  be  studied  with  effect  upon 
elaborately  carved  preparations,  or  in  casts  made  of  metal,  run  into 
the  bony  tubes,  spires,  and  chambers  of  which  it  is  composed.  As, 
however,  it  is  never  the  seat  of  surgical  operation,  and  cannot  be 
examined  during  life,  the  relative  situations  and  proportions  of  its 
parts  are  of  less  practical  importance  to  the  surgeon  than  either  of 
those  portions  of  the  ear  already  described. 

23 


354  ANATOMY  OF  THE  LABYRINTH. 

The  vestibule,  a  small,  irregular  chamber,  varying  in  size  in  different 
individuals,  but  averaging  about  the  one-sixth  of  an  inch  in  its  longest 
diameter,  is  situated  immediately  behind  the  foramen  ovalis  ;  it  has 
three  dilatations,  called  ventricles  or  horns, — a  superior  and  two  infe- 
rior; one  before  and  the  others  behind.  Its  inner  wall  consists  of 
the  sieve-like  plate  which' separates  it  from  the  internal  meatus  audi- 
torius,  and  through  which  pass  the  filaments  of  the  portio  mollis  and 
some  blood-vessels.  Anatomists  have  described  with  great  minute- 
ness each  hole,  elevation,  or  depression  in  this  portion  of  the  internal 
ear,  the  enumeration  of  which,  in  a  practical  work  of  this  description, 
would  be  out  of  place. 

The  semicircular  canals  are  three  tubes,  each  somewhat  more  than 
the  half  of  an  irregular  circle,  which  exist  in  the  temporal  bone, 
toward  the  upper  and  posterior  side  of  the  vestibule,  into  which  they 
open  by  both  extremities ;  but,  as  two  of  them  have  a  common  aper- 
ture, there  are  but  five  openings  from  these  tubes  into  that  chamber. 
Two  of  jfchese  canals  have  their  arches  turned  upwards,  and  hence 
their  position  is  described  as  vertical, — the  one  superior,  the  other 
posterior ;  the  third,  or  shortest,  is  horizontal. 

The  cochlea,  so  called  from  its  resemblance  to  a  snail-shell,  lies 
contiguous  to  the  vestibule,  and  rather  in  front  of  the  tympanum.  It 
is  a  conical  tube,  above  an  inch  and  a  half  long,  closed  at  the  distal 
extremity,  and  making  two  turns  and  a  half  round  the  central  pillar, 
— the  axis  or  modiolus ;  its  direction  is  from  left  to  right  in  the  right 
ear,  and  from  right  to  left  in  that  upon  the  opposite  side.  The  first 
turn  of  the  tube  of  the  cochlea  produces  that  bulging  upon  the  inner 
wall  of  the  tympanum  already  described  as  the  promontory.  Around 
the  axis  or  modiolus  a  thin  plate  of  bone  winds  like  the  thread  of  a 
screw, — the  lamina  spiralis,  the  shelf  formed  by  which  is,  in  the 
recent  state,  completed  by  membrane,  and  thus  the  passage  is  divided 
by  this  spiral  septum  into  two  scal^.  The  superior,  or  external,  or 
vestibular  scala,  opens  into  the  vestibule ;  the  larger,  or  scala  tym- 
pani,  which  is  inferior  and  internal,  opens  into  the  cavity  of  the  tym- 
panum by  the  fenestra  rotunda.  These  two  divisions  of  the  cochlea 
formed  by  the  spiral  lamina  communicate  at  the  extremity,  in  conse- 
quence of  that  bony  shelf  separating  from  the  axis  and  turning  out- 
ward, so  as  to  present  a  hook-like  termination. 

Two  delicate  canals  likewise  exist  in  this  portion  of  the  petrous 
bone, — the  aqueduct  of  the  cochlea, — a  mere  venous  conduit, — which 
extends  from  that  tube,  near  the  fenestra  rotunda,  to  the  margin  of 


ANATOMY  OF  THE  LABYRINTH.  355 

the  jugular  fossa ;  and  the  aqueduct  of  the  vestibule,  which  leads 
from  the  posterior  wall  of  that  cavity,  near  the  common  opening  of 
the  two  semicircular  canals,  to  the  upper  surface  of  the  petrous  bone, 
a  little  behind  the  internal  meatus,  where  it  is  lined  by  a  reflection 
of  dura  mater. 

In  the  recent  state,  the  whole  extent  of  the  osseous  labyrinth  is 
lined  by  a  fine  fibro-serous  membrane,  which  is  intimately  adherent 
to  its  surface,  extends  into  the  aqueducts,  completes  by  a  double  layer 
the  spiral  septum  of  the  cochlea  already  alluded  to,  forms  the  inner 
lamina  of  the  membrane  of  the  fenestra  rotunda,  and  also  covers  the 
base  of  the  stapes  at  the  fenestra  ovalis.  Its  external  surface  acts 
as  a  periosteum,  and  its  internal  secretes  the  perilymph  or  liquor 
Cotunnii.  This  fluid  permeates  the  entire  labyrinth,  passing  by  the 
heliocotrema  or  that  passage  which  exists  round  the  top  of  the  modio- 
lus, and  thus  completes  the  circuit  between  the  stapes  at  the  fenestra 
ovalis,  and  the  tympanic  cavity  at  the  fenestra  rotunda. 

Occupying  two  portions  of  the  osseous  labyrinth,  and  to  a  certain 
degree  supported  by  the  perilymph,  we  find  a  membrano-nervous 
texture,  called  the  membranous  labyrinth,  which  is  the  fundamental 
or  true  essential  portion  of  the  organ  of  hearing.  It  is  composed  of 
•a  small  bag,  denominated  the  common  or  vestibular  sinus,  which  sends 
tubuli  through  the  semicircular  canals,  and  is  in  contact  with  its 
osseous  surrounding  walls  only  where  the  latter  are  pierced  by  those 
nervous  filaments  which  ramify  within  it ;  but  does  not  enter  the 
cochlea. 

The  labyrinth  receives  its  vascular  supply  from  arteries  derived 
from  the  basilar,  and  sometimes  the  cerebellar,  which  enter  by  the 
internal  auditory  foramen. 

The  seventh  pair  of  nerves,  having  arrived  at  the  meatus  auditorius 
internus,  divides  into  the  portio  mollis  or  the  auditory,  and  the  portio 
dura  or  facial.  The  latter,  separating  from  the  former,  enters  the 
aqueduct  of  Fallopius,  which  leads  forwards  and  outwards  to  the 
hiatus  Fallopii,  where  it  enlarges  into  the  form  of  a  ganglion.  Its 
subsequent  course,  around  the  roof  and  posterior  wall  of  the  tympa- 
num to  the  stylo-mastoid  foramen,  has  been  already  described.  The 
portio  mollis  divides  in  the  meatus  auditorius  externus  into  two 
branches,  which  are  separated  by  a  bony  ridge :  the  large  anterior 
one  proceeding  to  the  cochlea ;  the  lesser  posterior  branch  having  its 
destination  in  the  vestibule  and  semicircular  canals,  and  being  chiefly 
distributed  upon  the  membranous  labyrinth,  and  in  the  enlargements 


856     MALFORMATIONS  OF  THE  INTERNAL  EAR. 

denominated  ampullae,  at  the  commencement  of  the  membranous  tubes 
of  the  semicircular  canals.  The  anterior  branch  or  nerve  of  the 
cochlea  proceeds  to  the  base  of  the  axis,  and,  dividing  into  a  number 
of  delicate  filaments  which  pass  through  the  substance  of  that  stem 
of  bone,  are  distributed  betAveen  the  osseous  plates  of  the  laminae 
spiralis,  at  the  edge  of  which  they  terminate,  by  a  very  free  anasto- 
mosis, in  minute  fibrillae,  and  finally  end  in  delicate  papillae  in  the 
membranous  portion  of  the  spiral  laminae. 

MALFORMATIONS    OF   THE   INTERNAL   EAR. 

Congenital  malformations  of  the  labyrinth  have  received  much 
attention,  and  minute  dissections  of  such  are  accumulating  from  year 
to  year ;  but  as  yet  pathologists  have  not  been  able  to  connect  the 
peculiar  deficiencies  in  hearing  with  the  post  mortem  appearances 
observed.  The  entire  labyrinth  has  been  found  one  undivided  cavity, 
without  a  vestige  of  either  cochlea,  vestibule,  or  semicircular  canals, 
and  not  having  any  communication  with  the  tympanum.  In  other 
cases  the  labyrinth  has  been  altogether  deficient,  and  there  was,  con- 
sequently, a  total  absence  of  the  essential  parts  of  the  organ  of  hear- 
ing. The  fenestrae  are  sometimes  deficient,  or  their  membranes  ossi- 
fied. The  osseous  labyrinth  has  been  found  but  imperfectly  deve- 
loped, so  that  the  membranous  labyrinth  was  partially  uncovered. 
The  cochlea  occasionally  forms  but  one  turn  and  a  half ;  and  has  also 
been  found  in  a  mere  rudimentary  state,  presenting  an  irregular  cul- 
de-sac,  without  any  axis  or  spiral.  The  semicircular  canals  are, 
however,  the  portion  of  the  internal  ear  most  frequently  found  mal- 
formed ;  they  have  been  observed  smaller  than  natural,  altogether 
wanting,  partially  impervious,  or  only  two  out  of  the  three  existing. 
The  aqueducts  have  been  found  preternaturally  large,  particularly 
that  of  the  vestibule,  which,  in  each  instance  detailed,  contained  like- 
wise an  unusual  quantity  of  fluid,  apparently  the  perilymph.  The 
labyrinthine  cavity  has  been  seen  filled  with  a  substance  resembling 
cheese ;  it  is  said,  that  the  perilymph  or  labyrinthine  fluid  has  been 
found  deficient  or  altered  in  quantity,  but  this  statement  requires 
confirmation.  Finally,  the  auditory  nerve  itself  has  been  found 
weak,  atrophied,  or  altogether  wanting.  In  all  the  foregoing  in- 
: stances  of  deviation  from  the  normal  state,  the  subjects  of  them  have 
been  born  deaf,  and,   consequently,  remained  dumb.     For  further 


WOUNDS    AND    INJURIES    OF    THE    LABYRINTH.        357 

information  on  this  subject,  the  reader  is  referred  to  the  Appendix 
on  Deaf-Dumbness.^ 

WOUNDS  AND  INJURIES  OF  THE  LABYRINTH. 

Of  fractures  passing  through  the  internal  ear  and  their  results,  I 
have  already  given  a  description  at  page  314,  so  that  it  is  unnecessary 
here  to  recapitulate  that  portion  of  the  subject.  Injuries  of  the  in- 
ternal ear  can  only  be  produced  by  great  violence  applied  to  the 
skull,  or  from  some  small,  sharp,  penetrating  instrument  passing 
through  the  tympanum  into  the  labyrinth,  by  either  of  its  two  exter- 
nal apertures.  Cases  of  this  kind  must,  consequently,  be  very  rare. 
One  very  remarkable  instance  occurred  in  the  practice  of  M.  Spe- 
ranza,  of  Parma,  which  has  gone  the  round  of  the  jom'nals,  and  been 
copied  into  most  of  the  works  upon  aural  surgery.  It  is  that  of  a 
man,  aged  20,  into  whose  ear  a  sharp  needle  was  thrust :  he  screamed 
violently  on  the  instant,  and  immediately  fell  down  senseless.  Shortly 
afterwards  he  became  delirious,  was  then  seized  with  violent  convul- 
sions, and  died  on  the  fourth  day  after  the  accident.  On  examina- 
tion, the  membrana  tympani  was  found  lacerated,  and  the  cavity  of 
the  tympanum  filled  with  pus,  the  chorda  tympani  nerve  was  divided, 
and  the  ossicula  displaced ;  the  fenestra  ovalis  was  open  and  appa- 
rently lacerated,  and  fragments  of  the  stapes  were  found  driven  into 
the  vestibule :  so  that  it  is  manifest  the  needle  passed  into  the  laby- 
rinth through  that  aperture.  The  membrane  lining  the  labyrinth 
was  found  much  injected,  and  the  auditory  nerve  in  a  disorganized 
state.  The  membranes  of  the  brain  exhibited  all  the  symptoms  of 
inflammation,  and  that  portion  of  the  encephalon  in  contact  with  the 
temporal  bone  was  filled  with  blood,  and  blood  was  also  extravasated 
between  the  dura  mater  and  the  petrous  bone. 

The  subsequent  injury  done  to  the  parts,  from  inflammation  follow- 
ing violence  must  be  very  great,  but  as  yet  we  have  not  a  sufiicient 
number  of  well-authenticated  cases  on  record  to  define  with  accuracy 

^  See  "  A  Contribution  to  the  Pathology  of  Congenital  Deafness,  by  Edwaid  Cock,"  in 
Guy's  Hospital  Reports,  No.  VIL,  October,  1838;  also,  the  article,  "  Ear  and  Hearing, 
Diseases  of,"  in  Cyclopaedia  of  Practical  Surgery,  by  Mr.  T.  Wharton  Jones  ;  Cases  re- 
corded by  Messrs.  Toynbee,  Dalrymple,  Thurnham,  and  Mondini ;  the  works  of  Schmalz, 
Kramer,  Tod,  Saissy,  Caswall,  Swan,  Lincke,  Deleau,  Itard,  Pilcher,  Frank,  Yearsley, 
Williams,  Scott,  Schallgruber,  Murer,  Mucke,  Bochdalek,  Wright,  and  others;  and  the 
various  books  upon  Diseases  of  the  Ear  and  on  Deaf-Dumbness ; — and  several  dissec- 
tions detailed  in  British  and  Continental  Medical  Works  and  Periodicals. 


358       WOUNDS    AND    INJURIES    OP    THE    LABYRINTH. 

what  are  the  precise  symptoms  of  inflammation  of  the  internal  ear, 
distinct  from  inflammation  of  the  cavitas  tympani  arising  either  from 
injury,  or  idiopathically  as  the  result  of  cold,  scarlatina,  or  any  other 
special  cause.  They  may,  however,  be  inferred  from  the  greater 
severity,  both  local  and  general,  of  the  characters  of  otitis  already 
described,  particularly  those  alluded  to  at  page  319,  as  the  third  ter- 
mination of  that  disease.  In  fact,  we  cannot  well  have  otitis  accom- 
panied by  high  fever,  and  attended  with  cerebral  symptoms,  without 
the  structures  of  the  internal  ear  being  engaged.  When  otorrhoea 
extends  to  the  cavity  of  the  tympanum,  it  is,  as  I  have  already  so 
frequently  stated,  not  only  difficult  to  limit  the  action  of  the  chronic 
inflammation  which  keeps  it  up,  but  hard  to  say  Avhere  it  may  end. 
Whether  inflammation  arises  spontaneously  in  the  labyrinth,  without 
the  tympanum  or  mastoid  cells  being  previously  engaged,  is,  I  should 
say,  very  doubtful ;  but  when,  from  ulceration  during  the  progress  of 
otorrhoea,  the  stapes  has  been  removed,  or  the  membrane  of  the 
fenestra  rotunda  destroyed,  we  can  well  imagine  how  easily  disease 
may  extend  to  the  lining  membrane  of  the  labyrinth,  and  finally  to 
the  bone  itself. 

Caries. — I  am  indebted  to  Sir  Philip  Crampton  for  an  examination 
of  one  of  the  most  extraordinary  pathological  dissections  of  diseased 
bone  perhaps  in  existence,  consisting  of  the  entire  internal  ear, 
cochlea,  vestibulum,  and  semicircular  canals,  with  a  small  portion  of 
the  inner  wall  of  the  tympanum,  which  he  drew  forth  from  the  meatus 
of  a  young  lady  who,  after  the  most  urgent  symptoms  of  inflamma- 
tion of  the  brain,  with  paralysis  of  the  face,  arm,  and  leg,  and  total 
deafness  of  one  side,  recovered  from  the  head  symptoms  and  the 
paralysis  of  the  extremities  after  a  copious  discharge  of  matter  from 
the  ear.  This  discharge,  the  paralysis  of  the  face,  and  deafness,  con- 
tinued some  time,  accompanied  by  occasional  attacks  of  pain  in  the 
ear,  till  one  day  Sir  Philip,  perceiving  a  portion 
'"■ "  ■  of  loose  bone  lying  deep  in  the  cavity  of  the  mea- 

tus, drew  forth  the  specimen  from  which  the  ac- 
companying illustration  has  been  made.  In  this, 
it  does  not  appear  that  the  hard  external  enamel 
of  the  bone  was  afiected,  but  the  scala  cochlea  is 
far  more  beautifully  displayed  than  could  possibly  have  been  done  by 
art.  Here  it  would  seem  that  caries  was  the  original  disease ;  but  in 
the  great  majority  of  instances  it  is  the  secondary  afiection  conse- 
quent on  neglected  otorrhoea,  a  knowledge  of  which  fact  should  im- 


MALIGNANT    GROWTHS. — TINXITUS.  359 

press  upon  us  the  necessity  of  carefully  examining  into,  and,  if  possi- 
ble, removing  aural  discharges  in  any  stage  of  theii'  course. 

3Ialignant  growths  from  the  ear  have  been  already  described  at 
pp.  .205,  207,  and  346.  In  one  instance  the  disease  appeared  in  the 
form  of  a  polypous  growth  proceeding  from  the  meatus,  and,  for  the 
reasons  described  at  page  206,  probably  extending  from  without  in- 
wards. In  the  case  related  at  page  346,  the  disease  bui'st  through 
the  mastoid  process,  and  appeared  to  have  its  seat  in  the  cells  of  that 
bone.  "  The  fungi  of  the  dura  mater,"  says  Mr.  T.  "\Y.  Jones,  "which 
so  readily  destroy  the  bones,  and  make  their  way  into  all  their  open- 
ings, sometimes  get  into  the  tympanum,  and  from  thence  appear  at 
the  auditory  passage."  Cases  of  malignant  fungus  of  the  ear  have 
likewise  been  related  by  Mr.  Travers  and  Mr.  Wishart.^  In  the  dis- 
section of  the  case  recorded  by  the  latter,  it  was  found  that  a  part  of 
the  squamous  portion  of  the  temporal  bone  had  been  absorbed,  and  that 
a  piece  of  the  tumor,  the  size  of  a  small  egg,  had  passed  through  it  into 
the  cranium,  and  pressed  upon  the  brain.  Tubercular  deposits^  have 
been  found  in  the  ear,  and  also  in  connexion  with  the  auditory  nerve, 
of  which  a  case  occurred  in  the  practice  of  M.  Chomel. 

Osteosarcoma  has  likewise  been  known  to  engage  both  the  internal 
and  middle  ears,  but  it  has  not  been  observed  to  commence  originally 
in  either  of  these  cavities. 

Of  tinnitus  auriutn  1  have  already  written  at  page  90,  to  which 
section  I  would  here  refer  the  reader.  It  is  but  a  symptom ;  yet  it 
is  one  that  should  be  carefully  attended  to,  especially  in  cases  where 
we  do  not  find  a  sufficient  amount  of  organic  change  in  the  ear  to 
account  for  it  in  any  way.  In  such  cases,  it  behoves  the  practitioner 
to  institute  such  strict  inquiries  as  may  determine  whether  the  noise 
experienced  is  the  result  of  any  local  affection,  head  disease,  or  de- 
rangement of  some  distant  organ.  This  can  only  be  determined  by 
a  careful  examination ;  and  although  the  proofs  derived  from  such 
may  be  of  a  negative  character,  they  are,  nevertheless,  highly  valu- 
able. I  am  at  this  moment  acquainted  with  more  than  one  case  for 
which  I  was  consulted  years  ago  on  account  of  "noises  in  the  head," 
and  "singing  in  the  ears,"  in  which  there  was  no  apparent  aural 
disease,  and  little  or  no  loss  of  hearing,  the  subjects  of  which  I  have 
since  seen  tottering  through  the  streets  hemiplegic,  or  with  that  form 

1  Travers,  in  the  Lancet ;  Wishart,  in  the  Edinburgh  IMedical  and  Surgical  Journal 
vol.  vii.,  1811. 

^See  a  case  related  by  Chomel,  in  Medical  Gazette,  vol.  xx.,  p.  284. 


360  OTALGIA    AND    IIYPEKCUSIS. 

of  senile  paralysis,  probably  from  softening  of  the  brain,  in  wbich  the 
knees  and  hips  are  bent,  and  the  patient  slips  along  the  flagway, 
becoming  prematurely  "the  lean  and  slippered  pantaloon,"  bending 
at  every  step,  and  dragging,  if  one  may  so  say,  his  legs  after  him. 
In  some  other  cases  of  tinnitus,  unaccounted  for  by  aural  disease,  for 
which  I  have  been  consulted,  I  have  subsequently  heard  of  the 
patient's  death  from  apoplexy  or  paralysis. 

The  existence  of  Otalgia,  or  neuralgic  pain  in  the  ear,  of  a  non- 
inflammatory character,  and  not  caused  by  pressure,  or  lesion  of  any 
description,  has  been  questioned  by  writers  on  aural  surgery ;  and, 
on  the  other  hand,  has  been  rather  too  implicitly  believed  and  pre- 
scribed for  by  the  general  body  of  the  profession.  So  far  as  my  own 
experience  extends,  I  am  compelled  to  admit  its  existence,  but  it  is  a 
rare,  a  very  rare,  form  of  disease.  We  can  only  diagnose  it  by  a 
careful  inspection  and  examination  of  all  the  parts  susceptible  of  such 
inquiry,  aided  by  the  history  of  the  case  and  the  general  appearance 
of  the  patient.  In  each  of  the  three  cases  which  I  can  at  this  moment 
call  to  mind,  as  having  been  affected  with  true  otalgia,  they  were  all 
young  females,  two  of  them  highly  hysterical,  and  the  third  suffering 
from  uterine  derangement.  The  pain  in  the  ear  was  described  as  of 
a  most  excruciating  character ;  it  only,  however,  lasted  a  certain 
length  of  time ;  it  was  of  an  intermittent  character,  and  generally 
came  on  about  the  same  period  in  the  four-and-twenty  hours,  resem- 
bling, in  many  respects,  brow-ague,  and  those  neuralgic  pains  which 
often  affect  the  eyeball  in  young  persons.  Upon  examination,  there 
was  no  trace  of  inflammation  in  the  meatus,  membrana  tympani,  or 
the  cavity  of  the  tympanum ;  and  these  negative  proofs,  together  with 
the  periodic  return  of  the  pain,  the  total  freedom  from  annoyance 
during  the  intervals,  and  the  absence  of  ail  cerebral  symptoms,  are, 
I  believe,  the  only  sure  diagnostics  of  nervous  pain  in  the  ear. 

In  one  of  the  cases  which  came  under  my  notice,  there  likewise 
existed  an  intense  degree  of  exaltation  of  hearing,  which  lasted  for 
many  weeks,  but  was  most  acute  during  the  paroxysm  of  pain,  when 
the  slightest  noise  was  intolerable.  In  that  instance  the  sound  of 
knives  and  forks  at  dinner  appeared,  more  than  all  other  noises,  to 
produce  a  paroxysm  of  Hypercusis.  I  have  likewise  seen  this  affec- 
tion, which  is  analogous  to  photophobia,  or  intolerance  of  light,  which 
so  frequently  accompanies  ocular  and  cerebral  diseases,  unattended 
by  either  otalgia  or  otitis ;  it  is  also,  as  every  practical  physician  is 
aware,  a  symptom  of  fever  and  other  diseases  of  the  nervous  system. 


NERVOUS    DEAFNESS.  *  361 

In  some  forms  of  hysteria,  and  in  cases  of  mental  aberration  and 
lunacy — as  those  familiar  with  such  know  full  well — the  patients 
often  complain  of  all  manner  of  noises,  whisperings,  and  unnatural 
sounds ;  but  these  are,  I  believe,  generally  the  result  of  a  disordered 
imagination,  like  those  ocular  spectra  which  afHict  certain  individuals. 
But,  even  independent  of  such  cases  as  the  foregoing,  there  are  per- 
sons who  cannot  bear  particular  noises,  owing  to  some  peculiar  idio- 
syncrasy,— like  those  alluded  to  by  Shakspeare,  who  could  not 
contain  themselves  when  "the  bagpipe  sings  i'  the  nose."  How  far 
such  affections  depend  on  disease  of  the  auditory  nerve,  or  a  morbid 
condition  of  the  chorda  tympani,  I  cannot  say. 

The  treatment  of  otalgia  must,  to  a  certain  degree,  depend  upon 
the  character  and  constitution  of  the  patient ;  but  all  those  cases 
which  I  have  treated  gave  way  in  time  to  tonics  and  change  of  air. 
Of  the  former,  the  preparations  of  bark  and  iron  are  the  most  effica- 
cious ;  large  doses  of  quinine,  in  conjunction  with  black  drop,  aromatic 
spirits  of  ammonia,  and  camphor,  will  often  succeed  in  warding  off 
an  attack;  and  when  once  the  periodicity  of  the  disease  has  been  dis- 
turbed, it  generally  becomes  amenable  to  treatment.  I  have  also 
found  the  citrate  of  quinine  and  iron  very  useful  in  such  cases. 

NERVOUS   DEAFNESS. 

Having,  throughout  the  previous  portion  of  this  work,  and  in  vari- 
ous other  writings,  labored  to  show  that  the  great  mass  of  diseases  of 
the  ear,  producing  impairment  of  hearing,  are  the  result  of  inflamma- 
tion in  some  of  its  many  Protean  characters,  I  cannot  be  expected  to 
have  much  to  advance  upon  the  subject  of  what  is  called  Nervous 
Deafness,  or  impaired  functional  power  of  the  auditory  nerve,  irre- 
spective of  organic  disease  in  the  brain,  or  structural  alterations  of 
the  textures  of  the  organ  of  hearing.  That  there  are  many  cases  of 
deafness,  with  or  without  tinnitus,  which  do  not  exhibit,  during  any 
period  of  their  course,  the  slightest  change  from  the  normal  condition 
in  those  parts  of  the  ear  susceptible  of  examination ;  in  which  the 
Eustachian  tubes  are  free ;  where  the  mucous  lining  of  the  tympanic 
cavities  is,  so  far  as  our  means  of  inquiry  extend,  healthy ;  in  which 
the  membrana  tympani  is  perfectly  natural  both  in  structm-e  and 
position,  and  the  external  meatus  does  not  show  any  symptom  of 
disease, — every  one  who  treats  aural  affections  upon  a  large  scale 
must  admit.     But,  that  they  are  as  frequent,  or  bear  that  proportion  to 


362  NEEVOIIS    DEAFNESS. 

the  other  diseases  of  the  ear  which  some  authors  would  lead  us  to 
believe,  is,  I  think,  a  most  erroneous  and  untenable  position,  not 
borne  out  by  fact,  and  not  warranted  by  analogy  with  the  diseases  of 
other  organs,  especially  those  of  the  eye.  Paralysis,  so  called,  of 
the  portio  mollis  of  the  seventh  pair  of  nerves,  one  would  think,  from 
reading  books,  or  hearing  professional  men  pronounce  opinions  on 
the  subject — Avas  a  very  common  affection ;  I  believe,  however,  that 
heretofore  it  has  been  used,  like  the  term  "  scrofula,"  as  a  cloak  for 
ignorance  or  inability  of  making  an  accurate  diagnosis.  The  surgeon, 
having  made  up  his  mind,  from  a  careful  examination  of  the  physical 
signs,  both  positive  and  negative,  and  also  the  history  of  the  case, 
that  it  arises  from  impaired  function  of  the  auditory  nerve :  has  next 
to  determine  whether  the  seat  of  the  disease  be  in  the  expansion  of 
the  nerve  within  the  labyrinth :  at  its  origin  in  the  brain,  or  in  some 
portion  of  its  course  within  the  cranium, — either  from  pressure  arising 
from  tumors  and  other  mechanical  causes,  congestion,  softening, 
atrophy,  or  any  of  the  many  diseases  to  which  the  encephalon  is 
liable  at  all  periods  of  life.  As  I  have  already  stated  at  page  359, 
with  regard  to  tinnitus,  so  in  respect  of  chronic  deafness  not  charac- 
terized or  accompanied  by  any  trace  of  morbid  lesion  in  the  ear,  have 
I  seen  the  person  so  affected,  in  process  of  time,  longer  or  shorter  as 
the  case  might  be,  show  symptoms  of  cerebro-spinal  disease,  in  like 
manner  as  complete  amaurosis  with  dilated  pupil  is  often  the  fore- 
runner of  apoplexy,  paralysis,  or  epilepsy,  &c.  Such  cases,  in  which 
the  deafness  is  but  a  premonitory  symptom,  are,  however,  compara- 
tively few ;  yet  I  have  known  some  instances  in  which  the  patient 
went  to  bed  in  perfect  health,  and  on  awaking  was  totally  deaf,  and 
never  heard  afterwards.  Fright  has  likewise  suddenly  deprived  young 
persons  of  hearing.     Such  cases  are  generally  incurable. 

Cophosis,  or  total  deafness,  coming  on  gradually,  and  unaccom- 
panied by  any  symptom  but  noise  in  the  ear,  is  a  much  less  frequent 
affection  than  total  blindness  produced  by  amaurosis.  For  the  most 
part,  the  persons  affected  with  nervous  deafness,  even  in  the  severest 
form,  can  be  made  to  hear  through  the  medium  of  an  ear-trumpet. 
Still,  if  we  judge  from  the  expression  of  their  own  feelings  and  their 
countenances,  we  are  led  to  believe  that  their  privation  is  much  greater 
than  those  completely  deprived  of  sight.  There  is — with  the  excep- 
tion of  some  few  instances  with  which  I  am  acquainted,  in  which 
infirmity  has  not  biassed  natural  amiability — a  restless  anxiety  de- 
picted in  the  countenance  of  the  partially  deaf,  and  a  suspicious  look, 


NERVOUS    DEAFNESS.  363 

which  is  never  observed  in  the  blind,  who,  even  when  left  alone,  gene- 
rally wear  a  smiling  countenance,  as  if  pleased  with  their  own  reflec- 
tions. A  greater  amount  of  sympathy  is  generally  awarded  to  the 
blind,  who  are  more  dependent  upon  others  for  their  comforts  and 
amusements.  They  it  must,  however,  be  remembered,  suffer  simply 
from  their  privation;  the  deaf,  in  addition,  often  labor  vmder  the 
most  harassing  noises,  and  from  partially  hearing  what  is  said,  without 
being  able  to  understand  the  purport  of  general  conversation,  and 
being,  moreever,  much  confused  by  the  Babel  of  sounds  around  them, 
should  claim  more  sympathy  than  is  generally  awarded  them.  Those 
who  have  completely  lost  the  power  of  catching  anything  said  in 
conversation,  and  who  can  only  be  communicated  with  by  a  trumpet, 
— generally  hearing  but  the  good  and  pleasant  things  of  life, — are  in 
a  much  happier  condition  than  the  former.  It  is,  in  all  probability, 
owincr  to  the  confused  noises  with  which  the  deaf  are  troubled,  and 
to  the  belief  which  many  of  them  entertain,  that  people  are  speaking 
about  them,  when  they  do  not  hear  what  is  said,  that  so  many  per- 
sons of  that  class  become,  as  they  advance  in  life,  unhappy  and 
morose. 

That  diseases  of  the  ear  are  hereditary  there  is  little  doubt ;  and 
next  to  the  congenitally  deaf  and  dumb,  I  believe  that  nervous  deaf- 
ness is  the  most  frequent  form  in  which  the  disease  is  transmitted ; 
but,  whether  arising  from  some  congenital  peculiarity  of  the  auditory 
nerve,  which  only  becomes  developed  in  after  life,  I  cannot  say.^  I 
know  many  cases  in  which  mothers  and  daughters  are  deaf.  I  have 
also  known  several  members  of  the  Same  family  and  its  collateral 
branches  deaf  of  one  ear.  In  the  upper  ranks  of  society  the  disease 
is  much  more  frequent  in  females  than  males.  The  subjects  of  it  are 
generally  of  a  sallow  complexion,  of  a  phlegmatic  disposition,  with  a 
thin,  cold  skin,  and  languid  circulation,  and  some  are  said  to  have  a 
low  state  of  sensibility  of  the  auricles.  In  most  cases  the  patients 
hear  better  when  travelling  in  a  carriage,  or  wherever  they  are  ex- 
posed to  a  certain  amount  of  noise  attended  with  increased  vibration ; 
but  this  is  occasionally  observed  in  other  forms  of  ear  disease. 

The  disease  commences  insidiously,  and  is  often  more  frequently 
remarked  by  the  friends  than  by  patients  themselves,  who  are  usually 
most  unwilling  to  admit  the  possibility  of  their  not  hearing  as  well  as 
other  people.     Many  deaf  persons  trace  back  the  first  adbession  of 

1  Upon  the  subject  of  congenital  and  hereditary  deafness,  see  the  Chapter  on  Muteism. 


364  NERVOUS    DEAFNESS. 

disease  to  gvief,  affliction,  sudden  mental  emotion,  to  a  shock,  or  to 
some  great  calamity.  In  many  cases  it  first  appears  after  cliild-birtli ; 
but  it  ordinarily  comes  on  between  twenty  and  thirty-five  years  of 
age.  It  generally  commences  on  one  side,  but  sooner  or  later  extends 
to  both  ears,  although  the  patient  almost  always  hears  better  on  one 
side  than  the  other.  It  is  strange,  but  nevertheless  true,  that  in 
general  the  musical  ear  remains  unafi"ected ;  persons  will  play  in  per- 
fect time  who  can  scarcely  converse.  In  nervous  deafness,  especially 
in  females,  the  patients  invariably  hear  worse  on  being*in  any  way 
excited,  as  by  suddenly  seeing  a  stranger  undergoing  a  medical  exa- 
mination, &c.  I  think  males  hear  rather  Better  after  dinner.  Both 
sufi"er  much  from  depressing  emotions. 

Tinnitus  aurium,  so  common  an  attending  symptom  on  every  form 
of  aural  and  many  cerebral  diseases,  is  a  frequent  but  not  an  invaria- 
ble companion  of  nervous  deafness.  It  may  exist  at  the  commence- 
ment of  the  disease,  and  be  lost  in  after  life ;  but,  except  under 
excitement — and  in  the  majority  of  such  cases  I  believe  the  disease 
is  cerebral — it  seldom  supervenes.  The  existence  or  non-existence  of 
this  single  symptom  led  Dr.  Kramer  to  divide  nervous  deafness  into 
the  Erethitic,  in  which  the  diminution  of  hearing  is  accompanied 
sooner  or  later  with  noises ;  and  the  Torpid  form,  in  which  there  is  a 
total  absence  of  that  symptom, — the  former  being  incurable,  the  latter 
curable,  according  to  his  opinion,  by  the  application  of  medicated  va- 
pors to  the  mucous  membrane  lining  the  Eustachian  tube,  the  cavity 
of  the  tympanum,  and  the  mastoid  cells  !  Of  that  gentleman's  views, 
his  explanation  of  nervous  deafness,  and  his  statistics  of  ear  diseases, 
I  have  already  fully  and  freely  expressed  my  opinion  both  in  this 
work  (see  pp.  41  and  110)  and  elsewhere.-^     These  doctrines,  and  this 

'  See  the  correspondence  between  Dr.  Kramer  and  myself,  in  the  London  Medical 
Times  and  Gazette  for  20th  November,  1852,  and  12th  and  1 9th  February,  1853.  In  Dr. 
Kramer's  reply  to  my  first  letter,  he  says,  "  I  cannot  forbear  advising  Mr.  Wilde,"  and, 
by  Mr.  Wilde,  all  other  readers,  examiners,  and  criticisers  of  his  work,  "to  lay  aside  for 
ever  the  first  edition  of  my  '  Diseases  of  the  Ear,'  "  by  which  he  alludes  to  the  second 
German  edition,  which  appeared  as  the  first  English  translation  in  September,  1837. 
Now,  this  work  of  Dr.  Kramer's  having  gained  for  him  considerable  reputation ;  having, 
I  am  free  to  acknowledge,  eflTected  much  good  in  reforming  the  state  of  aural  surgery  in 
Great  Britain ;  having  been  admirably  translated  by  Dr.  J.  R.  Bennett;  published  by 
Messrs.  Longman  at  considerable  expense  ;  and  having,  upon  the  faith  of  several  lauda- 
tory reviews,,  been  largely  purchased  by  the  profession  in  these  countries, — I  confess  I 
do  not  think  it  fair  for  the  author  to  come  out,  at  the  end  of  a  number  of  years,  with  a 
wholesale  criticism  of  his  own  production,  by  desiring  me  and  every  other  possessor  of 
the  work  to  lay  it  aside  for  ever ;  and,  forsooth,  because  alterations,  such  as  the  follow- 


NERVOUS    DEAFNESS.  365 

division  of  nervous  deafness,  were  caught  up  and  reiterated  by  Eng- 
lish aurists,  without,  in  my  opinion,  a  fair  and  careful  examination  of 
the  grounds  upon  which  they  were  founded. 

ing,  have  taken  place  in  a  new  edition  of  the  same,  "  as  the  result  of  a  twelvefold  more 
extended  experience,"  spread  over  a  period  of  upwards  of  sixteen  years.  One  of  the 
alterations  and  amendments  to  which  Dr.  Kramer  refers  runs  thus : — 

"  In  both  forms  of  nervous  deafness  I  have  almost  always  found  the  membrana  tym- 
pani  white,  like  paper,  and  opaque."     (English  Translation,  p.  260;   1837.) 

"  In  cases  of  nervous  deafness  I  have  not  seldom  found  the  tympanal  membrane  white, 
like  paper,  and  opaque."     (Last  German  Edition,  p.  722  ;   1849.) 

When  an  author  modifies,  or  altogether  discards,  opinions  which  Re  formerly  enter- 
tained and  promulgated;  and  that  his  new  views  are  the  result  of  increased  experience, 
a  more  extended  field  for  observation,  and  a  calm  consideration  of  the  opinions  of 
others,  we  cannot  but  honor  his  candor ;  but,  when  statistical  statements  are  reiterated 
and  put  forward  to  the  profession  as  facts,  which  were  not  only  compiled  under  an  erro- 
neous idea,  but  which  absolutely  formed  a  portion  of  the  basis  of  a  work  which,  although 
it  gained  considerable  reputation,  the  author  now  advises  us  "  to  lay  aside  for  ever,"  I 
think  we  have  a  right  to  ask  that  author  to  go  back  upon  his  materials,  and  to  re-arrange 
his  figures  from  the  date  when  he  first  began  to  modify  his  views.  When  Dr.  Kramer's 
first  English  edition  appeared,  in  which  he  believed  the  condition  of  the  membrana 
tympani,  in  nervous  deafness,  was  "  almost  always  wMte,  like  paper,"  he  stated  that  out 
of  300  cases  of  diseases  of  the  ear  from  all  causes,  152  were  instances  of  that  affection. 
In  1845,  he  gave  to  the  world  the  statistics  of  2,000  cases  of  diseases  of  the  ear,  in 
which  nearly  the  same  proportion  obtained,  for  1,028  were  attributed  to  "  nervous  deaf- 
ness;" but,  in  1851,  he  gives  an  account  of  2,000  additional  cases,  in  which  the  former 
proportions  are  considerably  modified,  for  only  1,875  were  attributed  to  "  nervous  deaf- 
ness ;"  and  I  entertain  a  strong  hope  that  Dr.  Kramer  will  live  long  enough  (and  I  wish 
him  long  life  and  success)  still  further  to  modify  his  views ;  and,  instead  of  "  not  seldom," 
to  state  that  he  has  "  very  seldom,"  or  "never,"  found  the  tympanal  membrane  white, 
like  paper,  and  opaque,  in  cases  of  nervous  deafness. 

In  support  of  his  theory  Dr.  Kramer  gives  three  reasons  to  account  for  the  white 
paper-like  appearance  of  the  membrana  tympani,  which  he,  at  first  "  almost  always," 
and  afterwards  "  not  seldom,"  observed  in  cases  of  nervous  deafness.  Two  of  these 
are  negative,  and  one  positive,  if  speculative  assertion  for  a  pathological  appearance  can 
be  termed  positive. 

1.  The  first  is  that  the  person  so  affected  had  never  suffered  from  inflammation.  Now 
how  did  Dr.  Kramer  know  that  not  one  of  these  cases  ever  had  been  affected  with  in- 
flammatory action?  He  did  not  examine  the  ears  when  the  disease  first  commenced  ; 
and  pain  not  being  experienced  by  the  patient,  attention  was  not  attracted  to  the  part. 
Suppose  I  was  to  show  Dr.  Kramer  a  dozen  cases  of  impaired  vision,  with  discolored 
and  partially  disorganized  iris,  in  which  the  posterior  surface  of  that  structure  v/as  adhe- 
rent to  the  front  of  the  lens,  in  which  the  sclerotic  was  congested  and  partially  thinned, 
so  that  the  choroid  appeared  through  in  several  spots,  in  which  there  had  been,  during 
the  progress  of  the  disease,  little  or  no  pain,  and  but  slight  external  vascularity ; — or 
again,  cases  of  opaque  cornea,  the  result  of  strumous  corneitis,  in  which  there  is  often 
very  little  pain  experienced, — would  Dr.  Kramer  undertake  to  say  that  the  organ  had 
never  "  been  previously  affected  by  any  inflammatory  action  V 

2.  Dr.  Kramer  says  this  opaque  membrane  attending  nervous  deafness  presents  the 


366  NERVOUS    DEAFNESS. 

Other  German  writers,  with  that  morbid  taste  for  minute  subdivisions 
of  disease  which  characterizes  many  of  the  writers  of  that  country,  have 
still  further  subdivided  nervous  diseases  of  the  ear, — as,  for  instance, 
Dr.  Schmalz,  who,  in  the  work  alluded  to  at  page  43,  gives  the  fol- 
lowing subdivision  : — First,  Irritation  of  the  auditory  nerves  : — 1. 
Morbid  acuteness  of  hearing  ;  2.  Tone  echoes  ;  3.  False  hearing  ;  4. 
Double  hearing ;  5.  Noises  in  the  ears — which,  properly  speaking, 

same  concavity  externally  as  in  a  healthy  state,  while  that  which  restilts  from  inflam- 
matory action  is  invariably  connected  with  thickening  of  its  substance,  flatness,  and 
disappearance  of  its  normal  concavity.  This  collapsed  state  of  the  membrana  tympani, 
which,  he  says,  attends  the  opacity  unconnected  with  nervous  deafness,  he  himself 
formerly  laughed  at,  and  criticised  with  extreme  severity  all  those  who  entertained  such 
opinions. 

3.  "  The  condition  of  the  tympanal  membrane,  above  referred  to,  and  its  vi^hite  paper- 
like opaque  appearance,"  says  Dr.  Kramer,  "  is  always  joined  with  complete  want  of  ce- 
rumenous  secretion,  with  dryness  and  a  parchment-like  alteration  of  the  meatus  auditorius 
externus,  undoubtedly  the  consequence  of  impaired  action  of  the  vegetative  i:irocess  in 
the  affected  organ." 

This  want  of  cerumenous  secretion  and  dryness,  which  Dr.  Kramer  considers  a  diag- 
nostic of  nervous  deafness  is  a  very  old  phantasy  indeed,  and  totally  unsupported  by 
modern  investigations.  I  believe  it  to  be  the  result  either  of  the  same  inflammatory 
action  which  affected  the  tympanum  and  its  membranes,  having  extended  to  the  lining 
of  the  meatus  and  cerumenous  glands,  and  having,  consequently,  impaired  the  functions 
of  the  latter, — or  to  the  amount  of  syringing  and  other  interference  with  the  auditory 
tubes.  I  may  mention  as  a  fact  worthy  the  attention  of  Dr.  Kramer,  and  such  of  his 
readers  as  believe  that  deficiency  of  cerumen  is  a  symptom  of  nervous  deafness, — that 
I  have  lately  examined  the  ears  of  a  number  of  congenitally  deaf  and  dumb  persons, 
and  found  that  the  secretion  of  ear-wax  was  just  as  plentiful  in  them  as  in  the  same 
number  of  persons  with  healthy  ears  With  respect  to  Dr.  Kramer's  theory  of  account- 
ing for  the  opacity  of  the  membrana  tympani,  by  "  impairment  of  the  vegetative  pro- 
cess," I  really  am  unable  to  understand  it. 

So  fully  impressed,  however,  is  Dr.  Kramer  with  the  great  importance  of  Eustachian 
catheterism  in  all  cases,  and  of  the  diagnostic  value  of  the  want  of  cerumen  and  the 
state  of  the  external  conduits,  that  at  page  725  of  the  new  edition  of  his  book, — that  for 
which  he  says  he  is  now  alone  "  accountable," — he  writes,  "  in  by  far  the  greater  num- 
ber of  our  cases  the  ear  catheter  (^Ohrenkathetei-)  shows  the  auditory  tubes  (Gehorgcinge) 
dry,  and  even  covered  over  with  delicate  scales  or  broad  white  flakes,  so,  although  the 
tympanum  appears  not  unfrequently  transparent  and  shining,  it  is  much  more  frequently 
opaque,  dull,  and  white  as  paper,  conditions,  however,  which,  from  their  variability,  can 
in  no  way  be  considered  as  characteristic  marks  of  the  disease.  Much  more  important, 
even  decisive,  is  the  examination  of  the  middle  ear  by  the  catheter." 

At  page  370  I  have  given  an  extract  from  Dr.  Bennett's  translation,  as  to  Dr.  Kramer's 
explanation  of  the  way  in  which  the  fumes  of  ether  enter  the  labyrinth.  To  that  he 
may  now  reply  by  saying,  it  is  altered  in  the  new  edition.  True ;  but,  as  it  is  the  only 
mode  by  which  the  action  of  the  "  vapor  cure"  can  be  supported,  and  as  he  still  pro- 
mulgates that  doctrine,  and  supports  it  by  cases,  I  feel  that  I  have  a  right  to  criticise  it, 
and  expose  its  fallacy. 


NERVOUS    DEAFNESS.  367 

are  not  diseases,  but  symptoms : — and  secondly ;  Paralysis  of  the  au- 
ditory nerve,  induced  by  the  following  causes  :  1.  Congenital  and 
inherited  ;  2.  Senile ;  3.  Degeneration  of  the  nerve  of  hearing  ;  4. 
Violent  noises  ;  5.  Intense  frost ;  6.  Mechanical  injury  and  concus- 
sion ;  7.  Depressing  emotions  ;  8.  Typhus  and  nervous  fever ;  9. 
Apoplexy,  convulsions,  and  pressm'e  of  the  brain ;  10.  Determina- 
tion of  blood  to  the  head ;  11.  Anaemia  from  hemorrhage,  onanism, 
&c. ;  12.  Exanthemata,  especially  when  of  a  nervous  character  ; — a 
catalogue  which,  if  given  in  the  original,  or  turned  into  Greek,  might 
serve  to  swell  such  nosological  charts  as  that  to  which  I  have  alluded 
at  pp.  47,  48  ;  for  with  as  much  propriety  might  the  various  causes  of 
fracture  of  the  extremities,  or  of  inflammation  of  any  of  the  internal 
organs,  be  described  at  length  in  systems  of  medicine  or  surgery. 

Local  congestion  is,  I  think,  a  not  unfrequent  cause  of  cophosis,  as 
it  is  a  usual  cause  of  asthenopia  or  impaired  vision ;  but,  as  I  have 
already  stated,  some  of  the  very  worst  cases  of  true  nervous  deafness 
■which  I  have  seen  did  not  exhibit  the  slightest  alteration  in  structure 
in  any  of  the  parts  susceptible  of  examination. 

Nervous  deafness  must  be  treated  according  to  its  cause.  As  well 
might  the  ophthalmic  surgeon  be  asked  how  he  would  treat  loss  of 
sight, — passing  from  slightly  impaired  vision  to  complete  amaurosis, 
— as  an  aural  practitioner  be  required  to  afford  a  cure  for  deafness. 
The  treatment  of  nervous  deafness  has  occupied  the  attention  of  many 
distinguished  practitioners,  and  various  remedial  means  have  been  pro- 
posed for  the  cure  or  alleviation  of  this  hitherto  most  intractable  dis- 
ease ;  but  as  yet  neither  specific  nor  panacea  has  been  discovered  for 
functional  impairment  of  the  auditory  nerve,  unconnected  with  dis- 
eased brain  or  organic  changes  in  the  ear,  no  more  than  practitioners 
have  yet  discovered  a  cure  for  amaurosis,  loss  of  smell  or  taste,  or 
paralysis  of  the  nerves  of  either  motion  or  sensation.  Various  and 
manifold  are  the  remedies  which  have  been  proposed  by  authors ; 
most  of  them,  however,  have  been  crude  and  empmcal,  and  as  yet  none 
have  had  the  desired  effect.  Purgation,  and  acting  on  the  mucous 
membrane,  has  been  advised  by  one ;  emetics  by  another ;  counter- 
irritation  by  a  third ;  mercury  by  a  fom'th ;  electricity  and  galvanism 
by  a  fifth ;  and  fumigation  of  the  ca\dty  of  the  tympanum  and  Eus- 
tachian tube  with  medicated  vapors,  is  the  latest  novelty  with  which 
the  world  has  been  favored  for  the  treatment  of  this  disease.  Dr. 
Kramer  says  that  the  English  practitioners  have  departed  the  farthest 
from  the  right  path  in  the  treatment  of  this  affection  ;  and  is  pleased 


368  NERVOUS    DEAFNESS. 

to  criticise  their  opinions  with  his  usual  asperity :'  had,  however,  the 
Berlin  aurist  been  as  familiar  with  English  medical  literature,  or  the 
relative  merits  of  English  practitioners,  as  he  would  wish  his  readers 
to  believe,  he  would  not  have  classed  in  the  same  category  the  writ- 
ings and  opinions  of  the  late  John  Cunningham  Saunders,  with  those 
of  Mr.  John  Harrison  Curtis.  Saunders  was  not  only  fully  up  to, 
but  rather  in  advance  of,  his  time ;  and,  had  he  lived,  he  would  pro- 
bably have  done  much  to  advance  the  science  of  aural  as  well  as  oph- 
thalmic surgery.  How  did  he  treat  what  he  considered  to  be  nervous 
deafness  ?  Just  as  he  would  a  case  of  amaurosis, — first  taking  into  . 
account  its  probable  cause,  and  the  constitution  and  present  condition 
of  the  patient,  and  applying  to  it  the  common-sense  principles  of 
medicine  and  surgery.  He  employed  counter-irritation,  moderate 
purgation  when  necessary,  and  the  continued  use  of  mercurials,  with, 
subsequently,  tonics,  such  as  sarsaparilla  and  bark — believing,  as  he 
did,  that  the  loss  of  hearing  arose  from  congestion,  inflammation,  and 
effusion  of  lymph  or  serum  within  the  labyrinth ;  and,  although  forty- 
seven  years  has  elapsed  since  his  book  was  published,  I  do  not  find 
anything  proposed  in  the  foreign  literature  on  this  subject,  nor  have 
I  myself  met  with  cases  in  practice,  which  lead  me  to  deviate  mate- 
rially from  the  opinions  with  which  that  distinguished  surgeon  con- 
cludes his  work,  and  which  I,  therefore,  here  transcribe, — "  Confirmed 
nervous  deafness  is,  without  doubt,  hopeless  ;  but  I  know  not,  a  priori, 
how  to  determine  when  attempts  are  vain.  This  does  not  altogether 
depend  on  the  time,  but  the  degree  of  mischief  done  to  the  organ ; 
and  the  periods  at  which  it  becomes  incurable  must  be  various.  My 
object  is  to  direct  the  attention  of  the  practitioner  to  the  commence- 
ment of  this  species  of  deafness.  When  early  application  is  made, 
it  behoves  him  to  take  the  case  seriously  in  hand ;  for  no  time  is  to 
be  lost,  and  active  means  in  the  beginning  will  often  succeed.  It  is 
far  from  my  inclination  to  excite  a  hope  that  old  cases  of  this  species 
of  deafness  admit  of  cure.  I  have  never  seen  or  heard  of  any  cured 
by  any  plan  of  treatment  whatsoever ;  and  as  to  the  various  vaunted 
remedies  with  which  the  public  prints  are  daily  teeming,  I  know  them 
to  be  absolutely  inefl&cacious,  and  often  prejudicial." — p.  99. 

To  remedy  this  disease,  it  was  proposed  by  Itard,  and  has  been 
strongly  recommended  and  extensively  practised  by  Dr.  Kramer, — ■ 
and,  since  the  publication  of  his  work,  it  has  been  constantly  repub- 

*  In  the  last  edition  of  his  work,  Dr.  Kramer  says,  the  English  aurists  must  be  denied 
any  opinion  on  the  subject. 


NERVOUS    DEAFNESS.  369 

lished  b  J  authors, — to  cure  nervous  deafness  by  introducing  the  vapor 
of  acetous  ether  into  the  cavitas  tympani  through  the  Eustachian 
catheter,  to  which  is  attached  a  flexible  tube  communicating  with  an 
apparatus  containing  the  gas.  In  order  to  force  the  vapor  through 
the  tube,  various  ingenious-  devices  have  been  resorted  to  ;  but  latterly 
the  chief  upholder  of  the  system  conceived  that  the  ordinary  tem- 
perature of  a  warm  room  was  sufficient  to  vaporize  the  fluid,  and 
send  it  through  the  catheter  into  the  middle  ear ;  which  I  think  very 
questionable.  During  the  time  when,  jurare  in  verba  magistri,  I  em- 
ployed that  remedy  extensively,  my  mode  of  operating  was  as  fol- 
lows :  Having  introduced  the  catheter  into  the  mouth  of  the  Eustachian 
tube,  I  applied  the  air-press,  and  assured  myself  that  the  air  passed 
freely  into  the  tympanic  cavity.  A  large  glass  preparation-jar,  capa- 
ble of  holding  several  quarts,  was  then  fitted  with  a  cork  buffed  with 
leather  round  the  edge,  so  as  to  prevent  the  gas  escaping  ;  this  cork 
contained  three  apertures — to  the  first  was  attached  a  flexible  tube  com- 
municating with  the  Eustachian  catheter  ;  to  the  second  was  fitted  a 
small  metal  pipe,  furnished  with  a  funnel  and  stop-cock,  into  which  a 
few  drops  of  the  ether  were  poured  from  time  to  time,  as  the  patient 
became  conscious  of  the  quantity  contained  in  the  jar  being  expended  ; 
and  into  the  third  was  inserted  the  metallic  nozzle  of  the  tube  in  con- 
nexion with  the  air-press.  When  this  apparatus  is  about  to  be  used, 
the  free  extremity  of  the  first  tube  is  inserted  into  the  catheter,  the 
air-press  is  charged,  and  a  few  drops  (for  more  will  not  be  borne,  nor 
ought  to  be  used)  of  acetous  ether  is  poured  through  the  funnel  of  the 
second  tube  into  the  glass  vessel,  and  then  the  stop-cock  of  the  air- 
press  turned  just  so  much  as  to  permit  the  least  possible  stream  of 
air  to  pass  into  the  jar :  and  from  it,  charged  with  the  vapor  of  the 
ether,  it  passes  up  through  the  first  tube  into  the  middle  ear.  As 
soon  as  all  the  air  in  the  condenser  is  exhausted,  it  should  be  re- 
charged. The  patient  is  generally  conscious  of  the  vapor  gaining 
the  tympanum,  and  experiences  a  glow  of  heat  in  the  ear.  About 
ten  minutes  is  usually  sufficient  for  a  sitting,  and  the  patient,  if 
intelligent,  may  be  taught  how  to  regulate  the  force  of  the  stream 
of  air.  Dr.  Kramer  advises  the  remedy  to  be  continued  daily  for 
three  months. 

Now,  notwithstanding  the  vaunted  merits  of  this  cure  for  nervous 
deafness,  I  am  obhged  to  acknowledge,  although  I  gave  it  a  fair  trial, 
both  according  to  the  plan  proposed  by  Dr.  Kramer,  and  also  by  the 
means  detailed  above,  that  it  has  not  been  attended  with  success  in 

24 


370  NERVOUS    DEAFNESS. 

any  case  of  confirmed  true  nervous  deafness,  with  or  without  tinnitus ; 
neither  have  I  known  a  single  case  of  such  cured  by  this  mode  of 
treatment  in  the  hands  of  others.  I  have  not  thought  it  necessary  to 
enter  into  the  details  of  the  various  apparatus  which  have  been  in- 
vented, nor  the  different  substances  proposed  by  M.  Wolff  and  others, 
for  fumigating  the  middle  ear,  as  I  think  it  quite  unnecessary  to 
occupy  the  time  of  my  readers  therewith ;  those  who  wish  to  be 
informed  thereon  will  find  an  epitome  of  the  subject  in  Martell 
Frank's  book,  referred  to  at  page  43. 

Let  us  now,  in  the  name  of  common  sense,  inquire  into  the  ratio- 
nale and  the  modus  operandi  of  the  "vapor  cure."  The  auditory 
nerve,  expanded  within  the  membranous  labyrinth,  the  cochlea,  and 
semicircular  canals,  is  functionally  diseased — atrophied,  or,  as  some 
writers  term  it,  "paralyzed;"  and,  with  the  exception  of  a  deficiency 
of  cerumenous  secretion  in  the  external  meatus,  said  to  attend  this 
disease,  all  the  other  parts  of  the  ear — the  membrana  tympani,  and  the 
mucou^  lining  of  the  cavity  of  the  tympanum  and  Eustachian  tube — 
are  healthy.  Gas,  or  medicated  vapor  of  some  description,  is  applied 
to  the  middle  ear  for  the  purpose  of  stimulating  or  renovating  the 
dormant  action  of  the  parts  contained  within  the  cavity  of  the  laby- 
rinth,— just  as,  a  few  years  ago,  we  heard  the  virtues  of  the  vapor  of 
Prussic  acid,  when  applied  to  the  conjunctiva,  cornea,  and  eyelids, 
extolled  as  a  cure  for  amaurosis  and  cataract.  It  is  really  prepos- 
terous to  imagine  how  such  an  effect  could  be  anticipated ;  and  one 
would  be  inclined  to  call  in  question  the  common  sense  of  the  pro- 
posers, but  that  a  solution  may  be  offered,  at  least  in  Dr.  Kramer's 
case,  by  the  perusal  of  the  following  paragraph  from  his  book: — "It 
must  always  be  kept  in  view,  that  the  cavity  of  the  tympanum,  which 
first  receives  the  ether ous  vapor,  is  extremely  small,  and  that  even 
when  the  vapor  passes  through  this  cavity  into  the  labyrinth,  by  means 
of  the  foramen  ovale,  it  has  to  fill  an  equally  small,  or  even  still 
smaller,  space  than  that  formed  by  the  cavity  of  the  tympanum !" 
Can  it  be  that  Dr.  Kramer  has  forgotten  his  anatomy,  or  that  the 
school  of  Johannes  Muller  credits  the  assertion,  that,  in  an  ear  where 
the  structures  of  the  tympanum  are  perfect,  vapor  passes  through  the 
foramen  ovale,  closed  by  the  base  of  the  stapes  and  its  surrounding 
membrane  and  ligaments  ?  or,  does  endosmose,  the  only  principle  on 
which  a  plausible  explanation  can  be  offered,  really  exert  such  an  in- 
fluence as  that  here  alluded  to  ?  If  this  be  the  principle  (although  he 
does  not  make  any  allusion  to  it)  by  which  Dr.  Kramer  would  account 


NERVOUS    DEAFNESS.  371 

for  the  action  of  his  favorite  remedy,  one  would  have  thought,  from 
a  knowledge  of  the  anatomy  of  the  parts,  that  the  membrane  closing 
the  foramen  rotundum  would  be  a  better  medium  for  the  passage 
of  the  gas  than  the  base  of  the  stirrup  bone.  But  yet  this  is  not 
all ;  the  vapor  is  to  Jill  the  cavity  of  the  labyi'inth,  thus  replacing  the 
perilymph,  in  order  to  come  in  contact  with  the  expansion  of  the 
auditory  nerve !  This  opinion  is,  however,  on  a  par  with  the  pro- 
position made  by  the  same  author, — and  to  which  I  have  adverted  at 
page  111, — to  judge  of  the  state  of  the  auditory  nerve  by  the  intro- 
duction of  a  catgut,  an  ivory,  or  a  whalebone  bougie  into  the  cavity 
of  the  tympanum.  Mr.  Jones  has,  in  his  essay  already  referred  to 
at  page  45,  reiterated  all  these  absurd-  opinions  regarding  nervous 
deafness,  not,  however,  as  expressing  his  own  ideas  on  the  subject, 
but  prefaced  by  this  careful  proem, — "  The  following  is  a  sketch  of 
'Nervous  Deafness'  as  commonly  drawn  by  authors." 

To  these  objections  it  may  be  urged,  that  several  cases  have  been 
cured.  Granting  that  some  such  instances  have  been  recorded,  it  in 
no  wise  follows  that  the  disease  in  such  cases  was  one  of  pure  nervous 
deafness.  On  the  contrary,  I  believe  that,  where  benefit  has  been 
derived,  the  cause  of  deafness  was  originally  chronic  inflammation, 
and,  subsequently,  thickening  of  the  mucous  membrane  of  the  cavitas 
tympani — a  part  highly  endowed  with  nerves,  the  diseased  condition 
of  which,  as  already  pointed  out  by  Mr.  Swan,  must  materially  impair 
hearing. 

Mr.  Pilcher  has  recorded,  under  the  head  of  "  Nervous  Diseases  of 
the  Ear,"  a  case  of  "torpid  functional  derangement,"  of  which  the 
following  are  the  particulars,  as  given  at  page  318  of  his  book,  and 
afforded  partly  by  the  patient  and  partly  by  the  author  :  and  which 
I  have  selected,  not  in  a  spirit  of  hypercriticism  of  a  really  useful 
work,  but  in  the  hope  of  correcting  what  I  believe  to  be  an  error 
arising  out  of  the  too  hasty  acceptance  of  a  particular  doctrine.  A 
clergyman  says, — "At  the  age  of  sixteen  my  sense  of  hearing  was 
severely  injured  by  a  succession  of  violent  inflammatory  attacks  in 
my  ears.  About  thirty-fom-  years  have  elapsed  since  that  period; 
and,  during  all  that  time,  I  have  been  almost  entirely  deprived  of  the 
use  of  my  right  ear,  and  have  had  but  an  imperfect  use  of  my  left. 
.  .  .  .  In  the  course  of  last  winter  I  was  afflicted  by  a  severe 
and  obstinate  attack  of  quinsy,  which,  as  usual,  Yerj  much  affected 
my  hearing."  The  increased  deafness  thus  occasioned  continuing 
some  months  after  his  recovery  from  this  attack,  he  was  induced  to 


372  NERVOUS    DEAFNESS. 

submit  to  medical  treatment,  and  says,  "  I  soon  began  to  experience 
surprising  benefit,  particularly  in  my  right,  which,  for  the  greater 
part  of  my  life,  had  been  entirely  useless."  He  concludes  by  stating, 
that  his  hearing  has  been  perfectly  recovered.  The  only  record  given 
of  the  objective  symptoms  in  this  case  are  as  follows :  "  The  lining 
membrane  of  the  external  ears  of  this  gentleman  is  dry  and  scaly; 
the  Eustachian  tubes  are  large  and  pervious,  and  the  symptoms 
denote  a  torpid  condition  of  the  acoustic  nerve,  attended  with  occa- 
sional tinnitus  aurium."  A  diseased  condition  of  the  mucous  mem- 
brane of  the  left  nostril  presented  difficulties  to  the  introduction  of 
the  catheter  upon  that  side.  Not  one  word  is  stated  as  to  the  condi- 
tion of  the  meatus,  the  state  of  the  membrana  tympani,  or  the  sounds 
produced  in  the  cavity  of  the  tympanum  by  the  air  douche  in  this 
disease, — which  the  patient  himself,  it  must  be  remembered,  attri- 
buted, and  I  think  most  correctly,  to  a  succession  of  violent  inflam- 
matory attacks  in  his  ears ; — neither  is  the  hearing  distance  upon 
either  side  recorded  at  the  time  when  the  treatment  commenced,  or 
at  any  subsequent  period.  "The  treatment,"  says  the  author,  "pur- 
sued in  this  case  was,  the  application  of  the  vapor  of  acetous  ether 
two,  and_sometimes  three,  times  a  week,  the  patient's  avocations  not 
permitting  the  more  frequent  use  of  the  remedy;  when  the  vapor  did 
not  produce  a  sensible  effect,  the  much  diluted  mixture  of  ether  and 
water  was  injected."  Now,  I  challenge  the  whole  array  in  this  case, 
and  protest  against  its  being,  with  the  defective  details  above  stated, 
allowed  to  remain  upon  the  record  of  British  medical  literature  as  an 
instance  of  nervous  deafness  from  torpid  functional  derangement. 
But  the  same  difficulties,  the  like  defective  details,  and  illogical  rea- 
soning pervade  every  department  of  medical  literature,  as  must  be 
experienced  by  those  who  for  any  particular  purpose  have  occasion  to 
search  books  and  periodicals  for  cases  bearing  on  any  special  subject. 
Their  path  is  beset  with  difficulties ;  the  cases  which  they  have  seen 
quoted  as  proofs  of  a  particular  doctrine  turn  out,  when  they  come 
carefully  to  examine  them  in  the  original,  to  be  either  altogether  de- 
fective, or  by  no  means  proving  the  position  for  which  they  had  long 
been  employed.  I  have  often  thought  it  would  tend  to  bring  medi- 
cine up  to  the  state  of  a  more  exact  science,  if  some  one  with  suffi- 
cient knowledge,  honesty,  and  common  sense,  and  having  time  at 
command,  would  search  out  and  carefully  analyze  from  year  to  year, 
or  in  particular  branches  of  medical  science,  the  remarkable  cases 
that  are  continually  put  forth,  and  thus  purge  our  literature  of  those 


NERVOUS    DEAFNESS.  373 

which  I  will  not  say  are  unworthy  of  credit,  but  which  certainly  do 
not  aflFord  proof  of  that  for  which  they  were  related  by  their  authors. 
Mr.  Pilcher  has  also  propounded  a  doctrine  to  which  I  cannot  assent ; 
it  is  that  of  deafness  occurring  from  a  person  having  neglected  to  use 
the  ear.  I  cannot  well  understand  how,  except  by  stopping  the 
meatus,  any  one  can  neglect  to  use  the  ear. 

It  may  be  asked,  before  concluding  this  Chapter  upon  Diseases  of 
the  Internal  Ear,  whether  I  have  nothing  to  offer  but  criticism  of 
other  men's  statements  and  opinions  with  respect  to  the  cure  of  ner- 
vous deafness  ?  For  confirmed  cases  of  such,  particularly  when  of 
an  hereditary  nature,  I  have  nothing  to  offer  but  an  ear-trumpet,  and 
a  strong  recommendation  not  to  quack.  For  incipient  nervous  deaf- 
ness miich  may  be  done,  if  not  to  restore  perfect  hearing,  at  least  to 
arrest  the  further  progress  of  the  disease,  and  avert  a  condition  to 
which,  sooner  or  later,  the  unhappy  patient  may  be  reduced.  Coun- 
ter-irritation, long  kept  up  ;  the  judicious  use  of  mercurials  adapted 
to  the  age,  circumstances,  and  condition  of  the  patient,  and  persevered 
in  for  months ;  relieving  the  person  from  any  exciting  cause,  whether 
connected  with  plethora  or  debility,  which  may  appear  to  hasten  the 
catastrophe ;  and,  in  one  word,  by  improving  the  general  health  by 
such  means  as  any  experienced  physician  or  surgeon  can  apply,  will, 
and  often  does,  avert  complete  nervous  deafness.  Finally,  with  the 
exception  of  counter-irritation  behind  the  ears,  I  would  entreat  my 
readers  carefully  to  abstain  from  all  topical  applications. 

Of  cerebral  deafness,  or  that  arising  from  chronic  disease  of  the 
brain  or  its  coverings,  and  which  is  usually  accompanied  with  giddi- 
ness, derangement  of  the  stomach,  and  a  manifest  impression  upon 
the  general  health,  a  good  example  is  afibrded  in  the  case  of  the  cele- 
brated Dean  Swift,  on  which  I  have  already  remarked.^  For  such 
eases  an  issue  in  the  nape  of  the  neck  is  the  best  treatment. 

*  See  "  The  Closing  Years  of  Dean  Swift's  Life." 


374 


CHAPTER   VIIL 


OTORRHCEA. 


OtorrhcEa:  Statistics  of ;  Forms  of  Disease,  and  Parts  engaged;  Causes;  Prejudices 
against  Healing  ;  Metastasis. — Characters  of  Discharge. — Simple  Catarrhal  Otorrhcea  ; 
its  Treatment,  Local  and  General. — Astringent  Lotions. — Periosteal  Inflammation. — 
Complications  of  Otorrhcea :  Tympanic,  with  Perforate  Membrane. — Granulations. — 
Fungi. — Polypi :  their  Varieties ;  Treatment :  Excision  ;  Escharotics  ;  The  Snare. — Con- 
sequences of  Otorrhosa. — Caries  of  Mastoid  Process. — Facial  Paralysis ;  Double  and 
Single. — Discharge  from  Liternal  Ear. — Cerebral  AiTections  consequent  upon  OtorrhcEa! 
their  Fatal  Character :  Abscess  in  the  Neck  ;  Purulent  Infection  of  the  Lungs. — Ear 
Trumpets. 

As  the  great  majority  of  the  mflamraatory  affections  of  the  ear 
described  in  the  previous  chapters  of  this  work,  may,  and  do  fre- 
quently, terminate  either  in  suppuration,  or  in  effusions  of  serum, 
mucous,  or  muco-purulent  fluid,  it  necessarily  follows,  that  otorrJioea, 
or  a  discharge  from  the  ear,  must  be  a  very  frequent  disease.  A 
reference  to  the  Nosological  Table,  at  page  151,  will  show  many, 
though  not  all,  of  the  affections  which  may  end  thus  ;  for  frequently 
"a  running"  from  the  external  meatus  commences  without  any  pre- 
vious warning,  the  lining  of  that  tube  passing  imperceptibly  from  a 
cuticular  to  a  muco-secreting  surface ;  although  I  believe,  if  carefully 
examined  at  the  moment,  it  would  be  found  to  result  from  slight  and 
painless  inflammatory  action  in  the  part.  Although  otorrhcea  is  not, 
properly  speaking,  a  disease,  but  the  result  of  several  diseases,  yet, 
from  its  importance,  its  frequency,  its  constitutional  character,  and 
the  many  serious  diseases  which  it  originates,  I  have  here,  in  addition 
to  the  different  notices  of  it  throughout  this  book,  devoted  a  special 
chapter  to  its  consideration. 

"  A  discharge  from  the  ear"  is  by  far  the  most  frequent  aural  dis- 
ease of  these  countries  ;  but,  whether  owing  to  the  variableness  and 
humidity  of  our  climate,  the  prevalence  of  scrofula,  or  to  neglect,  it 
is  difficult  to  say.     As  may  be  seen  by  the  Table  given  at  page  108, 


OTORRHCEA.  375 

it  amounted  to  647  in  2385  cases  registered  from  all  causes,  or  about 
1  in  every  S^.  Of  these,  64  were  complicated  with  polypi, — 40 
males  and  24  females  ;  and  in  55  instances  the  membrana  tympani 
was  either  perforated  or  altogether  removed.  The  total  sexes  were, 
350  males,  and  297  females.  Otorrhoea  is  a  disease  of  infancy  and 
youth ;  it  seldom  appears  in  middle  life,  and  still  less  frequently  in 
advanced  years  ;  and  although  we  may  be  often  consulted  by  adults 
for  this  affection,  it  will  generally  be  found  that  the  discharge,  if  not 
of  very  recent  date,  came  on  years  before.  An  examination  of  the 
Registry  of  ear  cases,  given  in  Chapter  III.,  shows,  that  as  many  as 
83  in  200  were  either  at  the  moment  suffering  from,  or  had  at  some 
previous  period  labored  under  Otorrhoea  (see  page  135).  Of  these,  23 
had,  either  at  the  moment  or  at  some  previous  period  of  the  disease, 
a  discharge  from  both  ears  ;  25  from  the  right  only,  and  24  from  the 
left  alone.  With  respect  to  the  duration  of  the  disease  at  the  time 
these  patients  sought  ad\ice,  23  had  been  affected  for  different  periods, 
varying  from  a  month  to  a  year ;  in  12  cases  the  discharge  existed 
for  from  two  to  three  years ;  in  11  instances  for  from  four  to  five  ;  in 
13  cases  from  six  to  ten ;  and  in  13  for  over  ten  years. 

I  suppose  there  is  scarcely  a  member  of  the  profession  in  any  of 
its  various  branches,  who  has  not  been  frequently  applied  to  by  pa- 
tients, young  and  old,  of  both  sexes,  of  every  age,  and  among  all 
ranks  and  grades  of  society,  laboring  under  a  discharge  from  the 
external  ear — one  or  both — more  or  less  affecting  the  hearing,  in 
some  cases  attended  with  tinnitus  aurium,  and  in  all  giving  rise  to 
great  annoyance  and  inconvenience,  from  the  dirt,  and  often  fetid 
smell  which  it  occasions.  With  some  this  may  be  of  short  duration, 
and  with  others,  the  majority  of  whom  are  those  that  present  them- 
selves to  surgeons  practising  aural  surgery,  of  many  years'  continu- 
ance. Indeed,  one  only  wonders  how  sensible  men  could  go  through 
life  apparently  unconcerned  with  such  a  loathsome  disease  about 
them.  Many,  it  is  true,  endeavor  to  conceal  the  affection,  and  others 
are  deterred  from  taking  proper  advice  by  the  prejudices  of  their 
friends,  or  even  their  family  medical  attendants.  Let  me  illustrate 
the  general  progress  of  a  case  of  aural  discharge,  by  no  means  ima- 
ginary, but  presenting  as  the  type  of  hundreds  who  daily  apply  for 
advice  in  these  countries,  where  it  is  a  disease  of  such  common  occur- 
rence. 

During  infancy,  about  the  time  of  dentition,  or  at  any  other  period 
of  childhood — upon  the  sudden  subsidence  of  purulent  ophthalmia — 


376  OTOREHCEA. 

during  tlie  progress  or  as  the  sequel  to  any  of  the  exanthemata — either 
from  the  effects  of  cold,  the  manifestation  of  scrofula,  an  impaired 
condition  of  the  digestive  functions,  or  any  other  of  the  causes  in- 
ducing inflammation — a  child  is  suddenly  attacked  (often  in  the  middle 
of  its  sleep)  with  pain  in  the  ear,  frequently  of  the  most  excruciating 
character,  accompanied  by  brisk  fever,  and  at  times  even  producing 
delirium.  What  is  the  treatment  generally  had  recourse  to  ?  Hot 
oil,  turpentine,  essential  oils,  laudanum,  camphorated  spirit,  the  vola- 
tile liniment,  and  such  other  stimulating  substances,  are  unmercifully 
dropped  into  the  eaj.  And  if  it  be  a  grown  person,  in  addition  to 
all  these,  a  large  clove  of  garlic^  is  forcibly  thrust  into  the  meatus, 
and  a  hot  poultice  of  roasted  onions  or  figs  is  applied  to  the  auricle. 
As  already  observed  under  the  head  of  Otitis,  the  disease  proceeds, 
and  days  and  nights  of  extreme  anguish,  attended  with  much  restless- 
ness and  anxiety,  are  passed  by  the  sufferer.  No  examination  is  made 
all  this  time  of  the  parts  affected,  but  purgatives  are  freely  adminis- 
tered, and  perhaps  a  blister  is  applied  over  the  mastoid  process.  At 
length  suppuration  ensues,  and  when  the  discharge  has  been  fully 
established,  relief  is  experienced ;  the  disease  then  becomes  chronic, 
the  discharge  profuse,  flaky,  discolored,  sanguineous,  and  frequently 
fetid ;  partial  deafness  follows,  but  the  constitution  suffering  little, 
there  is  not  much  attention  paid  to  the  disease. 

Sometimes  the  discharge  commences  without  pain,  as  a  catarrhal 
inflammation  of  the  lining  membrane  of  the  meatus  auditorius  exter- 
nus,  and  if  in  an  infant,  or  a  child  or  young  jserson,  the  first  indication 
of  the  disease  is  the  soil  observed  on  the  cap  or  the  pillow.  In  a 
grown  person,  the  history  given  of  the  disease  is,  that  on  inserting 
the  end  of  a  towel,  or  the  point  of  the  finger,  to  relieve  an  itching  in 
the  meatus,  a  slight  moisture  was  seen  upon  it ;  and  that  then  the 
unpleasant  smell  attracted  attention,  and  in  time  the  amount  of  dis- 
charge and  subsequent  loss  of  hearing  became  apparent.  If  treat- 
ment be  employed  in  this  stage,  further  than  keeping  the  parts  clean 
by  syringing  with  tepid  water,  in  what  does  such  consist  ?  In  again 
having  recourse  to  nostrums  of  a  still  more  empirical  and  violently 
stimulating  nature  than  at  first,  such  as  tincture  of  cantharides,  oil 
of  originum,  creasote,  and  the  most  violent  escharotics,  which  are 
poured  into  the  meatus ;  and  in  order  to  exclude  the  air,  and  keep  in 
the  discharge,  a  ball  of  black  wool  is  crammed  into  the  ear. 

'  I  have  seen  three  cases  during  one  year  of  violent  inflammation  of  the  raembrana 
tympani  and  meatus  caused  by  the  use  of  garlic. 


OTORRHCEA.  377 

Should  the  friends  or  the  patient  seek  still  further  advice,  they  are 
generally  told  to  make  their  minds  perfectly  easy  about  the  matter ; 
that  it  is  entirely  a  constitutional  affection ;  and  that  as  the  person 
gains  strength  and  years,  the  discharge  will  cease,  hearing  return, 
and  all  will  be  well, — but  that  at  this  period  it  were  not  advisable  to 
check  the  discharge ;  an  issue  is  inserted  in  the  arm,  and  they  are 
recommended  sea-bathing,  with  sometimes  the  use  of  a  slightly  astrin- 
gent lotion.  Notwithstanding  all  this  doctoring  in  the  dark,  the  dis- 
ease generally  proceeds :  if  we  inquire  minutely  about  this  period, 
we  will  frequently  be  told  by  the  patient  or  the  attendants,  that  two 
or  three  small  bits  of  bone  had  come  away  with  the  discharge, — that 
this  discharge  varies  in  quantity  and  quality  from  time  to  time, — 
that  sometimes  it  becomes  thick  and  ropy,  of  a  yellowish  color  and 
mucous  consistence,  and  very  much  less  in  quantity ;  that  then,  upon 
the  person's  being  exposed  to  cold,  a  sudden  exacerbation  took  place, 
the  discharge  became  thin,  whitish,  flaky,  and  so  much  increased  in 
quantity  as  to  pour  out  of  the  meatus,  and  saturate  the  night-cap  and 
pillow. 

After  this  condition  has  continued  for  a  year  or  two,  and  we  come 
to  examine  the  state  of  the  parts,  we  find  the  margin  of  the  external 
meatus  thickened,  of  a  pale  red  color,  and  its  upper  portion,  in  parti- 
cular, coated  with  yellowish-brown  crusts;  from  the  under  margin, 
and  filling  the  canity  of  the  concha,  proceeds  a  slimy  muco-purulent, 
ropy  fluid,  of  a  greenish-yellow  color  and  fetid  smell,  while  the  mea- 
tus itself  is  filled  up  with  purulent  discharge,  in  the  centre  of  which, 
in  a  great  number  of  cases,  appears  a  small  granular  mass,  not  unlike 
the  apex  of  a  raspberry ;  and  on  lifting  up  the  auricle  to  examine  the 
ear,  by  pressing  on  the  tragus,  and  sometimes  on  the  mastoid  process 
also,  or  by  touching  the  passage,  pain  is  almost  invariably  complained 
of.  When  a  polypus  of  this  description,  appearing  through  the 
external  meatus,  is  perceived,  surgical  aid  is  again  generally  sought ; 
the  morbid  growth  is  grasped  with  a  forceps  or  ligature,  and  a  portion 
of  it  forcibly  torn  away,  but  as  the  root  remains,  and  soon  sprouts 
into  fresh  existence,  it  is  attempted  to  be  destroyed  by  powerful  escha- 
rotics,  and  a  stick  of  nitrate  of  silver,  of  the  size  generally  used  in 
commerce,  is  thrust  into  the  meatus  as  far  as  that  aperture  will  per- 
mit, or  the  torture  of  the  patient  bear.  From  this,  fresh  inflamma- 
tion and  ulceration  of  the  walls  of  the  canal  ensue,  causing  intense 
pain,  extending  through  the  head,  and  at  times  producing  irritative 
fever.     More  emollient  applications  are  then  had  recourse  to, — the 


378  OTORRHCEA. 

polypus  resumes  its  original  size,  very  seldom  extending  beyond  the 
external  opening  of  the  meatus,  and  is  either  carried  through  life 
with  the  deafness  which  it  causes,  or  f)roceeds  to  a  more  dangerous 
state,  as  already  described  at  page  206.  Suppose,  however,  as  it 
sometimes  happens,  that  this  polypus  or  fungus  does  not  grow,  or  at 
least  does  not  appear  externally,  the  peiriod  of  puberty  arrives ; 
the  constitution,  in  accordance  with  the  opinion  originally  expressed, 
does  take  on  a  new  action, — the  discharge  diminishes,  and  then  may 
even  finally  cease, — but  undoubtedly  with  either  a  considerable  dimi- 
nution or  a  total  loss  of  all  accurate  hearing. 

But  this  is  not  the  worst,- — the  discharge  may  not  then  cease  ;  the 
ulcerative  process  may  then,  or  at  any  previous  or  subsequent  period 
during  the  continuance  of  the  discharge,  suddenly  and  rapidly  extend ; 
the  membrana  tympani  is  destroyed ;  the  bony  walls  of  the  meatus  and 
the  tympanum  become  carious ;  the  ossicula  are  lost,  or  are  rendered 
incapable  of  performing  their  functions ;  the  disease  spreads  into  the 
mastoid  cells,  and  the  whole  of  that  process  of  the  temporal  bone 
becomes  carious ;  fistulous  openings  occur  behind  the  cartilage ;  a  thin, 
brownish,  highly  fetid  discharge  ensues ;  the  auricle  frequently  assumes 
a  bluish,  livid  appearance  ;  the  motor  portion  of  the  seventh  pair  of 
nerves  becomes  aifected,  or  absolute  lesion  of  its  substance  takes 
place ;  the  mouth  is  first  observed  to  be  slightly  drawn  towards  the 
opposite  side,  and  paralysis  of  one-half  of  the  face  quickly  follows ; 
the  palpebrse  remaining  apart,  give  the  globe  of  the  eye  a  peculiarly 
prominent  staring  appearance ;  the  cornea,  from  want  of  its  natural 
--covering,  and  the  injurious  effects  of  the  atmosphere,  abrades  and 
ulcerates  ;  the  ala  nasi  becomes  flattened ;  the  mouth  is  much  distorted 
(particularly  if  in  a  child  when  it  cries) ;  and  the  whole  cheek  and 
side  of  the  face  looks  fuller.  Hearing  is  in  most  instances  completely 
lost  on  that  side  ;  the  general  health  frequently  sinks  under  such 
accumulated  misery;  and  even  if  recovery  takes  place,  it  is  after 
months  of  suffering,  and  always  with  deformity.  At  times,  and  that 
not  unfrequently  too,  the  disease  spreads  still  farther  to  the  petrous 
bone ;  the  brain  and  its  membranes  participate  in  this  unhealthy  ac- 
tion ;  irritation,  fever,  rigors,  and  cerebral  symptoms  of  an  insidious 
nature  follow,  and  delirium,  convulsions,  coma,  and  death  ensue,  as 
shall  be  explained  more  fully  at  page  403 ;  or  the  patient  may  die 
suddenly  of  hemorrhage  from  an  open  carotid.  And  yet  this  is  the 
disease  thought  so  lightly  of  by  the  public  and  the  profession,  and 
described  as  "only  a  slight  running  from  the  ear." 


OTORRHCEA.  379 

After  the  frequent  mention  of  this  disease  in  the  previous  portion 
of  this  work,  it  is  unnecessary  to  enumerate  systematically,  all  the 
causes  of  otorrhcea} 

Porrigo,  crusta  lactea,  herpetic,  and  other  eruptions  extending  to 
the  ear,  produce,  particularly  in  unhealthy  children,  otorrhoea.  Me- 
chanical injuries,  such  as  blows,  or  the  introduction  of  foreign  bodies, 
will,  no  doubt,  produce  otitis,  and  afterwards  discharge ;  but  unless 
in  persons  of  marked  strumous  habit,  or  very  much  broken  in  health, 
it  seldom  continues  for  any  length  of  time  or  proceeds  to  anything 
serious.  Under  the  head  of  mechanical  injury  has  been  reckoned 
impaction  with  hardened  wax ;  but  I  can  only  say  I  have  never  wit- 
nessed it,  nor  do  I  believe  it  likely,  from  the  way  in  which  it  is 
formed  and  retained,  to  cause  otorrhoea.  I  have  several  times  met 
with  cases  of  otitis  ending  in  otorrhoea,  produced  by  improper  syring- 
ing of  the  canal,  under  the  supposition  that  the  deafness  arose  from  a 
plug  of  wax ;  whereas  the  fact  was,  no  wax  existed.  In  these  cases 
no  proper  examination  had  been  made,  or  this  error  would  not  have 
been  committed,  for  the  syringing  was  several  times  repeated,  and 
continued  for  nearly  half  an  hour  each  time.  Fevers  of  every  descrip- 
tion (and  indeed  long  illnesses  of  any  kind),  but  the  exanthemata 
more  particularly,  often  induce  aural  discharges. 

Cold  bathing  is  a  much  more  frequent  cause  of  otorrhoea  (I  suppose 
by  producing  slight  inflammation)  than  is  generally  suspected.  Mr. 
B.  had  otorrhoea  from  his  early  childhood  in  one  ear ;  which,  by  the 
advice  of  his  medical  attendant,  was  not  interfered  with,  although 
the  cophosis  it  occasioned  was  yearly  increasing.  In  his  instance,  the 
promise  of  amendment  in  time  was  realized,  at  least  as  regards  the 
discharge :  it  ceased  about  four  years  before  I  saw  him,  but  he  was 
then  almost  totally  deaf  at  that  side.  During  the  heat  of  summer  he 
bathed  in  the  sea,  and  almost  immediately  felt  an  unpleasant  sensa- 
tion in  the  affected  ear,  which  increased  to  pain  during  the  night; 
next  day  the  discharge  was  re-established.  On  my  seeing  him  some 
time  after,  and  examining  the  ear,  I  found  that  this  profuse  discharge 
proceeded  from  a  fungous  mass  that  grew  from  the  middle  ear, 
through  a  large  aperture  in  the  membrana  tympani,  over  which  it 
spread  like  the  head  of  a  mushroom,  and  which  opening  in  the  mem- 
brane had,  no  doubt,  occurred  during  the  progress  of  the  original 
otorrhoea.     I  mention  this  case  in  particular,  because  it  illustrates  the 

*  See  the  various  references  to  the  term  otorrhcEa  in  the  index. 


380  OTORRHEA. 

destructive  effects  upon  the  organ  by  neglect,  and  also  of  the  careful 
manner  in  which  patients  should  proceed  even  for  years  after  the 
running  has  ceased.  Persons  having  been  recommended  sea-bathing 
for  the  cure  of  the  discharge,  think  they  cannot  have  too  much  of  a 
good  thing,  and  continue  it  long  afterwards.  During  the  bathing 
season  I  meet  with  several  cases  of  primary  and  secondary  otorrhoea 
ascribable  to  this  cause. 

Erysipelas  of  the  scalp,  or  confined  to  the  auricle  and  meatus  alone, 
is  a  constant  cause  of  chronic  thickening  and  mucous  discharge  from 
the  ears,  but  it  is  seldom  profuse,  and  partakes  more  of  the  slight 
secretions  attendant  on  other  diseases  of  the  skin,  where  generally 
the  thickened  cuticle  continues  to  be  thrown  off  for  some  time ; — 
the  passage,  however,  never  becomes,  as  in  other  cases,  a  purely 
secreting  mucous  surface,  or  throws  out  granulations  or  vascular 
excrescences. 

Syphilis  and  gonorrhoea  have  been  enumerated  by  writers  as  pro- 
ducing discharges  from  the  ears,  but  I  have  never  met  such  cases ; 
and  I  do  not  think  that  the  instances  mentioned  by  authors  prove  that 
the  external  meatus  is,  in  its  ordinary  state,  susceptible  of  infection 
with  the  virus  of  either  syphilis  or  gonorrhoea  (see  page  196).  Gout 
has  also  been  said  to  produce  an  aural  discharge  (see  page. 259). 

If,  however,  there  is  a  disease  more  than  another  that  shows  a 
strumous  constitutional  taint,  I  believe  it  to  be  otorrhoea,  particularly 
that  form  of  it  which  appears  in  children  and  young  persons  without 
any  apparent  cause.  We  find  the  affection  either  commencing  origi- 
nally as  scrofula,  or  so  intimately  connected  with  a  scrofulous  condi- 
tion of  the  glands  of  the  neck,  and  the  general  appearance  of  the 
patient,  as  to  leave  no  manner  of  doubt  as  to  the  nature  of  the  affec- 
tion. This  form  either  commences  by  a  thin,  whey-like  discharge 
from  the  meatus,  arising  from  a  vitiated  state  of  the  lining  of  the 
tube  and  membrana  tympani,  or  by  suppurating  glands,  communi- 
cating, by  means  of  a  fistulous  opening,  with  the  auditory  canal.  For 
the  most  part  these  glands  have  likewise  an  external  superficial  open- 
ing; but  I  have  seen  some  cases  in  children  in  which  abscesses 
(generally  lying  immediately  anterior  to  the  tragus)  opened  into  the 
meatus  and  had  no  superficial  outlet ; — in  such  cases  pressure  on  the 
parts  in  front  of  the  tragus,  or  the  act  of  mastication,  pressed  the 
matter  into  the  meatus.  In  some  cases  of  phthisis,  as  I  have  stated 
at  page  323,  it  is  an  attendant,  and  then  the  discharge  possesses  all 
the  peculiarities  of  true  scrofulous  matter.     It  is  also  a  not  unfrequent 


OTORRHCEA.  381 

accompaniment  of  those  diseases  of  the  lachrymal  sac  denominated 
fistula  lachrymalis. 

When  otorrhoea  takes  place  during  the  progress  of  or  subsequent 
to  scarlatina,  it  occurs  in  three  ways,  either  by  direct  extension  of  the 
inflammation  of  the  skin  into  the  external  meatus  and  membrana  tym- 
pani,  and  there  producing  a  muco-purulent  discharge,  while  it  desqua- 
mates over  all  the  rest  of  the  body ;  by  the  diseased  condition  of  the 
'mucous  membrane  of  the  throat  (and  which  may  be  styled  scarla- 
tinous) passing  up  through  the  Eustachian  tube,  and  producing  sup- 
puration of  the  cavitas  tympani  and  perforation  of  its  external  sep- 
tum, as  already  described  at  page  324;  or  again,  by  the  abscesses 
which  take  place  in  the  neck  and  around  the  meatus,  opening  into  the 
fibro-cartilaginous  portion  of  that  tube,  and  there  inducing  and  main- 
taining, even  after  they  themselves  have  healed,  otorrhoea,  from  the 
diseased  state  of  this  portion  of  the  organ.  Measles  not  unfrequently 
induce  a  similar  condition,  but  in  that  disease  the  latter  mode  of 
propagation  is,  I  should  suppose,  much  more  rare ;  I  myself  have  not 
seen  any  such  cases.  Aural  surgeons  seldom  see  this  affection  of  the 
ear  till  long  after  the  subsidence  of  the  original  disease.  The  only 
satisfactory  account  given  with  or  by  the  patient  is,  that  when  they 
rose  out  of  the  fever,  they  were  deaf,  and  had  this  discharge. 

What  was  the  original  condition  of  the  ear  upon  the  setting  in  of 
the  discharge  ?  In  all  probability  it  consisted  in  simple  inflammation 
of  the  lining  membrane  of  the  meatus  and  membrana  tympani.  If, 
at  the  very  commencement  of  the  affection,  the  ear  was  properly 
examined  in  the  way  I  have  directed,  it  would  be  found  that  the  tube 
was  dry,  slightly  red,  and  painful  to  the  touch ;  that  the  secretion  of 
wax  was  either  wanting  or  scanty ;  that  the  membrana  tympani  had 
lost  its  peculiar  pearly  polished  appearance,  and  had  assumed  a 
slightly  pinkish  hue,  and  that  red  vessels  could  be  discerned  in  it, 
coursing  along  the  position  of  the  handle  of  the  malleus.  If  this 
examination  were  to  be  made  at  a  more  advanced  stage,  it  would  be 
found  that  the  cerumenous  secretion  had  entirely  ceased,  that  the 
cuticle  lining  the  meatus  had  become  thickened,  and  could  be  easily 
detached  in  whitish  flakes,  underneath  which  a  thin,  sero-purulent 
discharge  oozed  out,  while  the  membrana  tympani  had  become  more 
vascular,  and  when  the  thin  pellicle  of  cuticle  which  coats  its  external 
surface  was  cast  off  piecemeal  with  the  discharge,  it  would  be  seen  as 
red,  vascular,  and  as  villous  as  the  palpebral  conjunctiva  of  the  lower 
eyelid  in  catarrhal  ophthalmia :  the  position  of  the  malleus  would  then 


382  OTORRHCEA. 

■vyith  difficulty  be  observed.  Pieces  of  cuticle  are  then  daily  cast  out 
with  the  discharge.  If  we  examine  this  ear  a  few  months  subse- 
quently, we  shall  find  all  trace  of  cuticle  lost,  and  the  whole  tube 
lessened  in  size  by  thickening  of  its  walls,  and  also  converted  into  a 
muco-secreting  surface,  the  membrane  of  the  tympanum  being  not 
only  increased  in  vascularity,  but  absolutely  covered  with  papilliform 
granulations,  while  in  some  cases  at  this  period,  small  polypous  excres- 
cences will  be  discovered  growing  either  from  the  posterior  inferior 
aspect  of  the  tube,  where  the  bone  and  cartilage  unite,  or  sink  in  a 
sinus  near  the  tympanal  membrane.  At  a  still  more  advanced  period, 
the  membrane  of  the  tympanum  frequently  gives  way  by  ulceration, 
the  middle  chamber  opens  externally,  and  some  of  the  ossicula,  par- 
ticularly the  incus,  are  discharged ;  from  this  period  the  disease  may 
proceed,  even  to  a  fatal  termination,  in  the  manner  which  I  have 
already  described. 

To  remedy  these  affections  general  surgery  has  not  done  much,  so 
that  in  many  instances  medical  men  are  glad  to  get  rid  of  such  pa- 
tients ;.  and  this,  added  to  the  prejudices  in  the  minds  of  the  commu- 
nity at  large,  and  in  some  of  the  profession  too,  as  to  the  injurious 
eflFects  of  healing  or  "  drying  up,"  as  it  is  termed,  discharges  from  the 
ear,  has  caused  this  affection,  by  ignorance  and  apathy  on  the  one 
hand,  and  prejudice  on  the  other,  to  be  much  neglected  in  this  coun- 
try. I  am,  however,  happy  to  find,  that  since  the  publication  of  my 
Essay  upon  the  Causes  and  Treatment  of  Otorrhoea,  in  1844,  some 
change  has  taken  place  in  the  mode  of  managing  this  severe  and  very 
general  disease.  Still,  as  many  of  these  prejudices,  both  popular  and 
professional,  exist,  let  us  briefly  examine  some  few  of  the  reasons  as- 
signed for  the  non-interference  with  aural  discharges. 

A  lady  applied  to  me  with  her  son,  aged  seven  (one  of  those  cross- 
grained,  ill-reared  bears  of  children,  the  very  plague  of  doctors),  and 
asked  me  if  I  could  cure  him  of  "a  very  bad  deafness,"  with  which 
he  had  been  affected  for  the  last  five  years.  After  much  coaxing  and 
some  frightening,  I  was  permitted  to  look  into  the  ears ;  both  were 
filled  with  profuse  muco-purulent  discharge,  ropy,  fetid,  and  crusting 
on  the  external  parts ;  an  erysipelatous  blush  surrounded  the  thick- 
ened, scaly  orifice,  but  having  succeeded  in  cleansing  the  meatus,  I 
could  perceive  a  polypous  excrescence  filled  up  both  tubes.  Hearing 
was  much  improved  by  the  removal  (for  the  first  time  for  many 
months)  of  the  discharge.  Having  explained  the  nature  of  the  com- 
plaint, and  that  no  progress  towards  the  restoration  of  hearing  could 


OTOREHOEA.  383 

take  place  till  these  excrescences  were  removed,  and  the  discharge 
healed,  the  lady  at  once  informed  me,  that  unless  I  could  restore  her 
son's  hearing  without  drying  up  the  discharge,  she  would  have  nothing 
done,  for  that  some  of  her  children  having  died  of  water  on  the  brain, 
she  was  told  by  her  family  physician  never  to  let  this  running  from 
the  ears  be  stopped,  or  that,  if  she  did,  he  would  instantly  be  simi- 
larly affected.  I  do  not  mention  this  as  a  soKtary  instance,  but  as  a 
type  of  cases  that  I  meet  almost  daily,  and  chiefly  among  the  middle 
classes  of  society ;  the  poor  are  unacquainted  with  such  medical  re- 
finements. One  patient  is  afraid  of  apoplexy,  epilepsy,  or  paralysis  ; 
the  mother  of  another  fears  con\Tilsions,  hydrocephalus,  or  sore  eyes ; 
and  a  third  cannot  be  persuaded  that  the  discharge  is  not  connected 
with  his  brain. 

An  English  lady  desired  my  advice  for  otorrhoea,  more  on  account 
of  its  unpleasantness  than  for  any  other  reason  ;  the  history  she  gave  of 
it  was,  that  when  quite  a  girl,  at  school,  she  was  attacked  with  pain  in 
one  ear,  attended  by  a  discharge,  and  that  the  latter  had  continued 
ever  since,  sometimes  more,  sometimes  less,  the  hearing  always  varia- 
ble, but  yearly  becoming  worse,  till  now,  when  she  found  that  ear  of 
little  use  in  general  society.  Almost  immediately  upon  the  appear- 
ance of  the  discharge,  and  several  times  subsequently,  she  had  con- 
sulted a  practitioner  in  aui'al  sui'gery,  who  had  always  informed  her, 
that  to  heal  up  this  discharge,  profuse,  fetid,  and  disagreeable  as  it 
was,  would  be  highly  dangerous,  and  that  in  all  probability  it  would 
then  "  go  in  upon  her  brain."  I  found  the  cuticle  on  the  surface  of 
the  auditory  canal  white,  thickened,  and  coming  off  in  flakes,  beneath 
which  poured  out  a  thin  discharge ;  the  membrana  tympani  had  be- 
come perfectly  opaque,  thickened,  and  white  as  a  leucoma ;  it  was 
also  very  insensible  to  the  touch,  and  it  had  fallen  in  towards  the 
tympanal  cavity,  leaving  the  malleus  projecting  prominently  outwards  ; 
it  had  likewise  lost  all  power  of  vibration.  In  this  case  the  discharge 
was  removed  by  brushing  over  the  parts  with  a  strong  solution  of 
nitrate  of  silver,  syringing  night  and  morning  with  tepid  water,  and 
using  an  astringent  lotion  ;  hearing  was  but  little  improved,  yet  her 
condition  was  rendered  much  safer,  as  well  as  very  much  more  com- 
fortable, and  no  unpleasant  consequences  have  ensued  since  I  first  per- 
scribed  for  her  ten  years  ago. 

These  prejudices  are  of  old  standing  and  very  general  extension ; 
they  existed  equally  in  the  days  of  Saunders,  who  tersely  asks : 
"  What  argument  can  be  assigned  against  the  cure  of  this  disease  that 


384  OTORRHCEA. 

is  not  equally  conclusive  against  all  others  ?  Is  any  one  an  abettor  of  tlie 
obsolete  humoral  pathology  ?  He  will  contend,  that  the  stoppage  of  a 
drain,  which  nature  has  established,  is  pernicious,  and  the  morbid 
matter  will  be  determined  on  the  internal  parts  ;  but  how  can  such  a 
person  venture  on  the  treatment  of  any  disease,  even  the  healing  of  a 
common  ulcer  ?  Some  years  ago  I  thought  this  absurd  doctrine  had 
been  totally  exploded,  and  yet  I  constantly  hear  it  adduced,  to  deter 
parties  from  interfering  with  this  disease.  Is  a  child  the  subject  of 
it, — the  parent  is  told  it  is  best  to  leave  it  to  nature,  and  the  child 
will  outgrow  it.  Is  it  an  adult, — some  other  subterfuge,  equally  fu- 
tile, is  employed.  The  truth  is,  the  disease  is  always  tedious  and  diffi- 
cult, and  not  always  curable ;  and  many  are  disinclined  to  embar- 
rass themselves  with  the  case  who  have  not  candor  to  make  the  true 
statement." 

Many  of  those  errors  appear  to  have  arisen  with  Du  Verney,  and 
were  promulgated  by  Itard,  Lallemand,  and  their  followers ;  and,  be- 
cause it  was  observed  that  on  the  supervention  of  cerebral  disease, 
discharges  from  the  auditory  passages  have  lessened,  practitioners, 
mistaking  the  effect  for  the  cause,  have  been  led  to  believe  that  their 
sudden  "  drying  up  "  produced  a  metastasis  to  the  brain,  a  notion  as 
crude  as  it  is  unsupported.  Cases  may  have  occurred,  in  which  the 
improper  application  of  powerful  escharotics  and  stimulating  injections, 
thrown  by  means  of  a  syringe  into  the  external  meatus  and  tympanum, 
produced  many  of  the  disastrous  consequences  detailed  by  authors  ;  but 
no  record  has  come  down  to  us  of  the  precise  pathological  condition 
of  such  ears ;  nor  do  I  believe  that  such  ever  were,  or  could  at  the 
time,  have  been  properly  examined.  In  all  probability  these  cases 
were  ones  where  extensive  caries  had  already  existed,  and  the  internal 
ear  may  have  been  exposed  to  the  improper  remedies  ignorantly  ap- 
plied in  the  dark  by  persons  who,  having  committed  the  mischief,  sub- 
sequently raised  an  outcry  against  the  healing  of  aural  discharges  in 
all  cases. 

Itard,  one  of  the  chief  supporters  of  this  doctrine  of  non-interfe- 
rence has  related  a  case  in  which  death  ensued  upon  the  introduction 
of  some  linseed  oil  into  the  ear  of  a  child  affected  with  otorrhoea  ! 
That  case,  which  has  gone  the  round  of  almost  every  work  upon  aural 
surgery,  since  the  publication  of  Itard' s  book,  was  one  of  the  very  foun- 
dation stones  of  the  system  advocated  by  its  relator,  although  we 
know  nothing  of  its  previous  history,  nor  what  pathological  appear- 
ance the  bony  case  of  the  ear  or  the  brain  itself  presented.     Some 


OTORRHCEA.  385 

years  ago,  St.  John  Long  ascribed  the  death  of  one  of  his  patients 
to  the  application  of  greasy  substances  to  a  sloughing  sore  which  his 
liniment  had  produced ;  and  surely  with  as  much  medical  reason  as 
that  narrated  by  the  Parisian  aurist,  since  whose  time  our  works  upon 
aural  medicine  recommend  great  caution  to  be  observed  with  regard 
to  the  introduction  of  oily  remedies  into  the  ear  !  This  instance  is 
but  one  out  of  many  in  which  a  system  has  been  grounded  upon  as 
slender  facts  by  the  modern  French  school. 

If  the  bone  is  sound,  we  might  with  as  much  propriety  refuse  to 
cure  a  chronic  or  an  acute  ophthalmia,  an  ozena,  or  a  mucocele  ;  and 
even  if  the  bone  is  diseased,  remedies  should  also  be  had  recourse  to  ; 
but  of  this  form  presently.  Although  I  have  not  met  with  such  a  case, 
I  can,  however,  conceive  one  in  which  a  discharge  from  the  ears  had 
succeeded  upon  and  relieved  head  symptoms. 

Mr.  WilHams,  in  support  of  his  opinion,  that  "  it  is  better  not  to 
interfere  with  this  discharge  from  the  ears,"  says:  "If  suddenly 
checked  in  children  it  frequently  causes  skin  diseases,  swelled  glands 
in  the  neck,  inflamed  eyes,  and  sometimes  brain  aflections."  And 
again :  "  In  adults,  if  discharges  from  the  ear,  particularly  if  from 
the  internal  ear,  be,  from  any  circumstance,  suddenly  stopped,  head 
symptoms  immediately  commence ;"  and  in  support  thereof  he  adduces 
cases  related  by  Sir  B.  Brodie,  Itard,  Valsava,  andDrs.  O'Brien  and 
Denmark,  I  find,  however,  upon  carefully  examining  into  the  history 
and  post  mortem  appearances  of  these  instances,  that  in  four  there 
was  extensive  caries  of  the  petrous  portion  of  the  temporal  bone,  with 
apertures  leading  from  without  into  the  cavity  of  the  cranium,  but 
which,  for  want  of  proper  aural  inspection,  and  an  examination  into 
the  previous  symptoms  and  the  course  of  the  disease,  had  not  been 
even  suspected.  The  fifth  case  was  that  of  a  French  soldier,  who 
happened  to  have  otorrhoea  subsequent  to  fever,  and  who  left  the  hospital 
without  leave,  and  got  drunk.  After  he  was  brought  back  head  symptoms 
set  in,  and  then  we  learn  that  "the  discharge  was  entirely  suppressed." 
He  died,  and  on  inspection  after  death,  "  the  sinuses  were  gorged  with 
blood,  the  dura  mater  was  detached  from  the  bone  throughout  the 
whole  extent  of  the  right  temporal  and  part  of  the  occipital  fossae, 
and  in  the  same  situation  was  found  about  a  spoonful  of  serum,  almost 
yellow;"  the  dura  mater  was  Hkewise  coated  with  pus  on  its  internal 
surface,  the  arachnoid  thickened,  the  pia  mater  covered  with  puriform 
matter,  and  the  lateral  ventricle  contained  an  ounce  of  thick  serum. 
There  was  no  other  lesion  of  the  auditory  apparatus  than  the  loss  of 

25 


386  OTORRHEA. 

the  membrana  tympani,  which,  however,  it  was  prevously  stated,  had 
been  deficient  since  childhood.  Will  any  pathologist  take  upon  him- 
self to  say,  that  this  was  metastasis  from  the  ear,  and  not  direct  un- 
interrupted extension  of  disease  to  the  brain  ?  Such  cases  are  by 
no  means  uncommon  after  fever.  In  fine,  I  have  not  been  able  to 
discover  one  well-authenticated  instance  where  disease  of  the  head 
supervened  as  a  consequence  of  checking  otorrhoea  in  a  case  where 
the  condition  of  the  ear  had  been  previously  ascertained,  and  that 
disease  of  the  bone  had  not  existed  beforehand.  Men  do  not  distin- 
guished between  the  post  hoc  and  the  propter  hoc  ;  and,  mixing  up 
cause  and  effect,  regard  a  symptom  as  a  disease. 

Under  the  head  of  the  effects  of  otorrhoea,  this  subject  will  be  again 
considered,  but  two  questions  of  vital  importance  in  the  treatment  of 
the  disease  here  present:  one  as  to  prognosis;  the  other  as  to  the 
morbid  changes  to  which  long-neglected  aural  discharges  may  lead. 
With  regard  to  the  first,  it  should  always  be  cautious,  unless,  indeed, 
we  see  our  way  through  the  case  very  clearly,  and  for  this  reason — 
that,  so  long  as  otorrhoea  is  present,  we  never  can  tell  how,  when,  or 
where  it  will  end,  or  what  it  may  lead  to.  For  this  very  cause,  if 
no  other  or  better  existed,  the  old  doctrine  of  "letting  alone,"  or 
"leaving  to  nature,"  such  afibctions,  should  be  exploded,  and  we 
should,  by  every  means  in  our  power,  endeavor  to  heal  them. 

The  prognosis  must  much  depend  upon  the  cause,  severity,  and 
duration  of  the  disease ;  the  extent  of  parts  engaged  ;  the  presence  of 
morbid  growths  ;  and  the  age,  constitution,  habits  of  life,  and  position 
in  society  of  the  affected  person. 

When  the  disease  has  arisen  from  constitutional  taint,  as  a  painless 
running  on  the  one  hand ;  and  when,  as  the  result  of  scarlatina,  owing 
to  acute  inflammation,  and  suppuration  of  the  tympanum,  on  the 
other ;  it  is  always  difficult  to  manage.  In  any  case  of  long  standing, 
the  discharge  becomes  like  that  which  arises  from  a  fistula,  and  its 
treatment  is  very  tedious ;  and  in  every  case,  before  promising  the 
patient  permanent  relief,  we  should  assure  ourselves  of  the  total  ex- 
tent of  parts  engaged.  Simple  external  otorrhoea  merely  engaging 
the  meatus  and  outer  layer  of  the  membrana  tympani,  will  often,  in 
unhealthy  constitutions,  baffle  treatment,  and  continue  "  off  and  on  " 
for  months  or  even  years.  If  there  is  an  aperture  in  the  membrana 
tympani  ever  so  small,  through  which  the  cold  air  of  the  external 
atmosphere  can  come  in  contact  with  the  delicate  mucous  surface  of 
the  tympanic  cavity,  although  the  discharge  may  cease  for  a  time,  it 


OTORRHCEA.  387 

is  liable  to  break  out  again  upon  the  slightest  provocation.  Such 
perforations  may,  however,  as  already  stated  at  page  292,  heal  up ; 
but  if  a  considerable  portion  of  the  membrane  has  been  removed, 
although  we  may  improve  the  patient's  condition  in  every  respect,  we 
cannot  promise  that  the  otorrhoea  will  not  return.  So  long  as  poly- 
pus, even  of  the  smallest  size,  exists  in  the  meatus,  or  sprouts  from 
the  cavity  of  the  tympanum,  amendment  cannot  be  hoped  for  until  it 
has  been  removed.  When  the  bony  portion  of  the  meatus  is  denuded, 
or  that  caries  or  necrosis  exists  in  any  of  the  parts  from  which  the 
discharge  proceeds,  it  were  futile  to  expect  a  healthy  action,  until  the 
diseased  bone  is  either  absorbed  or  cast  off.  If  we  have  reason  to 
believe  that  the  internal  ear  is  engaged,  our  prognosis  must  be  still 
more  unfavorable ;  and  where  the  discharge  proceeds  from  malignant 
disease,  all  hope  must  be  abandoned. 

With  respect  to  the  nature  of  the  discharge,  it  varies  considerably 
at  different  times,  and  even  in  the  same  individual ;  from  a  thin, 
starch-like,  sero-mucous  fluid,  containing  scales  of  epithelium,  to  thick 
yellow  pus  ;  it  is,  however,  generally  muco-purulent,  containing  shreds 
of  mucus,  which  float  through  the  water  ;  it  is  sometimes  thin,  watery, 
and  sanguineous,  and  in  such  cases  the  disease  is  usually  complicated 
with  polypus ;  it  is  often,  particularly  in  young  children,  of  so  acrid  a 
natui'e  as  to  excoriate  the  auricle,  and  even  the  side  of  the  neck ;  in 
other  cases  it  is  exceedingly  fetid,  and  of  a  dark  drab  color.  The 
color  and  smell  have  been  relied  upon  as  means  of  diagnosis  by  seve- 
ral writers.  As  far  as  my  observation  extends,  I  cannot  agree  with 
the  rules  laid  down  in  books,  for  although  when  caries  of  the  bone 
exists,  the  discharge  is  generally  dark-colored  and  fetid,  yet  I  meet 
many  cases  in  which  both  these  characters  are  present,  without  any 
exposure  of  the  bone,  and  particularly  when  the  tympanal  membrane 
is  perforated,  and  when  the  fluid  comes  from  an  inflamed  mucous 
sm-face ;  but  it  may  exist  even  -without  this  destruction  of  substance. 

There  is  another  form  of  discharge  occasionally  met  with  in  the 
ears,  particularly  of  scrofulous  patients,  and  which  may  be  denomi- 
nated "caseous,"  from  its  resemblance  to  softened  cheese;  it  looks 
like  a  mixture  of  pale  cerumen  and  pus,  has  a  peculiar,  heavy,  sick- 
ening smell,  and  a  pasty  feel.  It  does  not  altogether  dissolve  in  the 
water  with  which  it  has  been  removed. 

The  division  of  otorrhoea  into  internal  and  external  merely  depends 
upon  the  pressure  or  absence  of  an  aperture  in  the  membrana 
tympani. 


388  OTORRHOEA. 

Witli  regard  to  the  treatment  of  otorrhoea, — our  first  step  must 
be  to  examine  minutely  the  condition  of  the  external  auditory  canal, 
first  syringing  out  the  tube  with  tepid  water,  and  then  submitting 
every  portion  of  it  to  the  action  of  strong  light  through  the  tubular 
speculum.  In  the  early  stage,  and  in  the  mildest  form  of  this  com- 
plaint, all  that  we  may  be  able  to  discover  is  a  pinkish,  vascular, 
slimy  condition  of  the  lining  of  the  whole  tube  and  external  layer  of 
the  membraue  of  the  drum,  which  latter  is  thickened  and  opaque,  and 
has  almost  invariably  a  fasciculus  of  red  vesicles  coursing  along  the 
line  of  the  malleus.  In  simple  external  otorrhoea,  I  generally  paint 
the  surface  engaged  with  a  solution  of  nitrate  of  silver,  ten  grains  to 
the  ounce,  with  a  fine  camel's  hair  pencil,  or  a  bit  of  cotton  on  the 
end  of  a  probe,  which  I  find  far  preferable  to  the  old  practice  of 
dropping  in  the  solution ;  as,  by  thus  rubbing  it  on  the  parts,  some 
more  and  some  less,  according  to  their  condition,  it  removes  a  quan- 
tity of  the  mucous  discharge,  which  adheres  with  great  tenacity,  and 
thereby  makes  its  eiSect  more  certain;  it  may  also  be  required  on 
some  particular  spots  only  ;  and  moreover,  by  this  method  the  concha, 
external  parts,  and  the  dress,  are  not  blackened  by  it.-^  This  appli- 
cation should  be  repeated  every  second  day,  and,  in  the  interim,  the 
ear  should  be  syringed  night  and  morning,  and  even  oftener  if  the 
discharge  accumulates,  with  plain  tepid  water,  from  a  gum  elastic 
bag,  which,  when  used  by  friends  or  attendants,  or  the  patient,  is 
much  preferable  to  the  usual  piston  syringe  ;  and  at  night  a  slightly 
astringent  lotion  may  be  poured  into  the  ear  till  it  fills  up  the  meatus, 
allowed  to  remain  there  for  a  few  minutes,  with  the  head  bent  to  the 
opposite  side,  and  then  permitted  to  run  out.  The  syringing  must 
not,  however,  be  over-done :  as  soon  as  the  discharge  begins  to  mode- 
rate, it  should  be  had  recourse  to  less  frequently ;  for  if  not,  it  will, 
particularly  in  the  hands  of  attendants,  serve  to  keep  up  the  irritation.^ 

'  It  was  with  considerable  surprise  I  read  an  article  by  Dr.  Bonnafont  in  the  Gazette 
des  Hopitaux,  recommending  a  powder  of  nitrate  of  silver  to  be  blown  into  the  ear,  for  the 
cure  of  ulcerations  attending  otorrhosa.  With  still  greater  wonder  and  regret  have  I 
seen  such  practice  quoted  and  recommended  in  British  journals.  A  more  empirical 
procedure,  except  that  of  a  farrier  blowing  powdered  white  sugar  and  quicklime  into 
the  eye  of  a  horse,  to  cure  it  of  the  "  Haws,"  I  never  knew  advocated.  With  as  much 
reason  should  powdered  caustics  be  blown  up  the  vagina,  or  the  rectum,  or  into  the 
throat  or  nose,  or  into  the  eye,  to  cure  a  spot  of  ulceration  on  these  parts,  as  into  the  ear; 
and  with  as  much  ease,  certainty,  and  security  can  an  ulcer  in  the  auditory  passage,  or 
on  the  membrana  tympani,  be  touched  with  caustic,  either  in  substance  or  solution, 
without  injuring  the  adjoining  surfaces,  as  into  any  of  these  cavities. 

*  Many  patients  imagine  they  can  syringe  their  own  ears ;  but  we  have  only  to  look 
at  their  attempts  to  do  so  to  see  how  ineffectual  they  are. 


0  T  0  R  R  H  (E  A.  .  389 

The  various  salts  wHcli  enter  into  the  general  composition  of  eye 
collyria  are  here  particularly  applicable,  especially  those  of  alum, 
lead,  zinc,  and  copper.  I  formerly  employed  the  lead  lotion  very 
extensively,  but  I  have  found  that  it  frequently,  even  without  coming 
in  contact  with  diseased  bone,  produces  a  blackened  discharge :  when 
it  is  used,  the  liquor  plumbi  will  be  found  the  safest  and  most  effica- 
cious preparation ;  and  the  lotion  may  be  preserved  clear,  and  either 
rose  or  elder-flower  water  employed,  by  the  addition  of  a  few  drops 
of  acetic  acid.  The  liquor  aluminis  composition  of  the  London  Phar- 
macopoeia is  that  which  I  now  most  frequently  prescribe.  Solutions 
of  tannin  will  also  be  found  useful  astringents. 

If  upon  examination  we  find  the  meatus  thickened,  and  it  and  the 
surface  of  the  membrana  tympani  pink  and  vascular,  a  leech  or  two, 
according  to  the  age  and  strength  of  the  patient,  should  be  applied 
every  third  day,  several  times.  When  the  discharge  is  fetid,  a  chlo- 
ride of  lime  lotion  used  occasionally  is  of  service,  being  slightly 
astringent,  and  correcting  the  disagreeable  smell. 

With  regard  to  cleanliness  and  syringing,  so  very  much  depends 
upon  it,  particularly  among  the  lower  orders,  that  the  surgeon  never 
can  sufficiently  impress  its  importance  upon  the  patient  or  the  atten- 
dants. In  simple  mucous  discharge,  without  polypus,  granulations,  or 
affections  of  the  deep-seated  structm-es,  it  is  the  chief  part  of  the 
treatment ;  and  yet  how  difficult  to  have  it  performed  regularly ! 
Allowing  the  discharge  to  accumulate  is  undoubtedly  one  of  the  prin- 
cipal means  of  perpetuating  otorrhoea  in  any  of  its  forms.  When  the 
meatus  becomes  a  secreting  cavity,  with  ulceration  of  its  walls,  it  re- 
sembles a  fistula,  and  the  longer  it  has  existed  the  more  difficult  it  is 
to  heal ;  and  this  fistulous  character,  especially  in  a  narrow  passage, 
promotes  the  continuance  of  a  slight  thin  discharge,  even  long  after 
the  granulations  or  other  producing  causes  have  been  removed.  The 
action  of  the  external  air,  therefore,  upon  this  secreting  surface,  simi- 
lar to  what  it  experienced  in  health,  can  never  be  too  much  observed. 
There  is,  however,  a  very  general  prejudice  to  the  contrary ;  for  in 
two-thirds  of  the  cases  of  otorrhoea  which  I  am  called  on  to  treat,  I 
find  the  orifice  of  the  meatus  filled  full  of  cotton  or  black  wool,  which, 
if  treatment  be  employed,  is  invariably  restored  to  its  position  after 
each  syringing.  Some  time  ago  I  was  consulted  on  account  of  a 
discharge  from  the  ears  of  Master  C. ;  it  was  then  of  two  years'  stand- 
ing, and  was  thin  and  whey-like.  He  had  been  under  medical  treat- 
ment during  the  entire  course  of  the  disease ;  generally  made  use  of 


390  OTORRHEA. 

syringing,  and  an  astringent  wash ;  never  ceased  to  take  tonic  mix- 
tures and  aperient  powders,  and  had  resided  twice  at  the  sea-side. 
On  examination,  I  found  the  auditory  passages  converted  into  secret- 
ing cavities,  but  without  fungi,  granulations,  or  caries,  and  with  the 
tympanal  membranes  still  perfect,  but  I  learned  that  he  had  worn 
plugs  of  cotton  in  his  ears  ever  since  the  discharge  commenced ;  and 
these  were  only  removed  once  in  every  two  days  in  order  to  syringe 
and  apply  the  lotion  !  By  throwing  aside  the  plugs,  syringing  twice 
a  day,  and  continuing  the  same  astringent  applications,  the  child  was 
cured  in  a  month.  It  is  scarcely  necessary  to  add,  that  the  moment 
the  ear-passage  becomes  a  muco-secreting  surface,  all  traces  of  ceru- 
men vanish,  and  it  is  not  in  the  generality  of  cases  until  months  after 
the  discharge  has  ceased  that  the  wax  reappears. 

With  regard  to  general  treatment,  a  very  remarkable  difference 
seems  to  exist  in  this  country  in  relation  to  the  management  of  the 
diseases  of  the  eye  and  the  ear ;  that  of  the  former  being  of  too 
local  a  nature,  while  that  of  the  latter  is  almost  exclusively  constitu- 
tional. How  frequently  do  we  see  a  case  of  pustular  or  rheumatic 
ophthalmia,  with  a  foul,  white,  loaded  tongue,  treated  by  a  caustic 
solution  dropped  into  the  eye,  or  an  astringent  lotion  applied  to  the 
eyelids — while  a  case  of  otorrhoea,  -without  any  derangement  of  the 
digestive  functions  or  general  health,  is  recommended  tonics,  sea-bath- 
ing, blistering,  and  an  issue  in  the  arm.  If  the  case  is  curable, — for 
it  must  be  borne  in  mind  that  only  a  certain  number  of  those  present- 
ing with  discharge  from  the  ear  are  amenable  to  treatment, — and  that 
we  have  fully  ascertained  the  cause  and  source  of  the  otorrhoea,  and 
have  reason  to  believe,  from  the  appearance  of  the  patient  or  the  his- 
tory of  the  case,  that  the  state  of  constitutional  health  assists  to  keep 
up  the  local  disease,  we  should  by  every  means  endeavor  to  act  on 
the  system.  Cod-liver  oil  and  Peruvian  bark  are  the  remedies  which 
I  have  found  most  conducive  to  this  end :  the  former  as  an  anti-stru- 
mous  fattener ;  the  latter  by  altering  the  established  tendency  to 
morbid  secretion ;  but  notwithstanding  that  otorrhoea  of  long  stand- 
ing is  reputed  to  be  entirely  a  constitutional  affection,  I  have  seldom 
occasion  to  prescribe  any  course  of  alterative  medicine,  unless  in 
cases  t)f  marked  strumous  habit,  and  when  the  glands  of  the  neck  are 
diseased.  With  regard  to  "drains"  and  counter-irritation,  we  may 
insert  an  issue  in  the  arm,  if  only  to  meet  the  prejudices  of  the  friends 
or  medical  attendants ;  but  sometimes  cases  occur  that  of  themselves 
not  only  warrant  but  demand  such  a  precaution;  for  instance,  where 


OTORKHCEA.  391 

disease  of  the  brain  had  appeared  in  other  members  of  the  family,  or 
that  the  aural  discharge  had  broke  out  on  the  subsidence  of  dis- 
ease of  the  skin  or  any  vicarious  outlet,  or  that  the  child  had  had 
convulsions  in  infancy,  etc. ;  but  these  are  the  exceptions  to  the  rule. 

Towards  the  close  of  an  otorrhoea  from  simple  chronic  otitis,  espe- 
cially in  children,  I  have  frequently  remarked,  that  they  are  liable  to 
fresh  attacks  of  otalgia,  and  sometimes  small  abscesses  form  round 
the  mouth  of  the  meatus.  These  are,  I  believe,  best  warded  off  by 
the  application  of  a  vesicating  liniment  behind  the  ears,  and  keeping 
up  gentle  counter-irritation  for  some  little  time  after  the  otorrhoea  has 
ceased.  For  this  purpose  the  croton  oil  dissolved  in  soap  liniment, 
or  the  tincture  of  iodine,  made  stronger  and  more  soluble  by  the  addi- 
tion of  a  little  hydriodate  of  potash  or  the  acetum  lyttas,  answers 
very  well. 

When  an  otorrhoea  of  long  standing,  from  whatever  cause  it  has 
arisen,  is  ceasing,  either  spontaneously,  or  as  the  result  of  treatment, 
1  have  found,  in  a  great  number  of  cases,  that  the  dermal  lining  of 
the  auditory  canal  becomes  enormously  thickened ;  and  the  cuticle, 
which  is  now  re-developed,  and  of  a  white  color,  very  like  the  appear- 
ance of  the  hands  when  long  exposed  to  the  action  of  hot  water,  as 
in  washing,  is  thrown  off  in  patches,  and  often  fills  up  the  passage 
completely.  Such  was  the  condition,  and  such  the  stage  of  the  dis- 
ease, presented  in  the  case  of  an  officer  who  had  been  affected  with 
an  otorrhoea  from  his  childhood,  described  by  Mr.  Earle  in  the  tenth 
volume  of  the  Medico-Chirurgical  Transactions.  To  that  case,  so 
admirably  described,  and  so  judiciously  treated,  I  would  refer  my 
readers,  as  a  type  of  the  mode  in  which  simple  chronic  otitis  ends. 
Such  a  case  need  not,  in  the  present  improved  state  of  aural  surgery, 
require  such  lengthened  treatment.  After  syringing  the  ear  well, 
all  the  thickened  cuticle  that  remains  may  be  easily  removed  through 
the  speculum  with  the  spatula  and  the  slender  forceps  figured  at  page 
184 ;  the  parts  may  then  be  touched  with  a  solution  of  lunar  caustic, 
and  when  the  discharge  has  ceased,  and  the  cuticle  has  become  thin- 
ner and  less  white,  the "  cure  may  be  completed  by  the  application  of 
ung.  hydrarg.  nitros  dil.,  laid  on  warm  with  a  camel-hair  brush. 

When  an  otorrhoea  has  ceased  for  a  time,  particularly  where  the 
tympanum  is  open,  a  thick  crust  of  inspissated  mucus,  like  that  which 
sometimes  grows  in  the  nose  in  cases  of  ozena,  fills  up  the  bottom  of 
the  cavity  of  the  meatus,  often  resembling  the  end  of  a  thimble, — as 
soon  as  it  becomes  dry  and  hard,  it  acts  as  a  foreign  body,  giving  rise 


392  OTORRHCEA. 

to  "  itching,  and  a  feeling  of  stuffing  and  great  uneasiness  in  the 
socket  of  the  ear^"  as  patients  frequently  express  themselves.  These 
crusts — of  which  many  instances  will  be  found  among  the  cases  in 
the  Ear  Registry — must  be  cautiously  removed  from  time  to  time. 

The  complications  that  render  otorrhoea  at  all  times  tedious,  and 
always  difficult  to  heal,  are  morbid  vascular  growths ;  of  these,  Crra- 
nulations  covering  over  the  face^  of  the  memhrana  tympani  are  not 
unfrequent.  In  such  cases  the  bottom  of  the  auditory  -tube  will 
appear  as  red  and  vascular  as  a  granular  eyelid,  and  it  is  to  an 
unpractised  eye  difficult  to  know  whether  it  is  the  surface  of  the 
membrane  or  the  inner  wall  of  the  tympanum  that  is  seen.  A  simple 
inspection,  by  means  of  a  strong  light,  will  generally  determine  this ; 
for  although  the  greater  portion  of  the  membrane  of  the  tympanum 
may  be  destroyed,  and  even  the  incus  cast  off,  still  the  malleus,  in  the 
great  majority  of  instances,  remains.  A  fine  probe,  such  as  that  de- 
scribed at  page  289,  will,  by  one  touch,  determine  whether  we  are 
percussing  a  thickened  membrane  or  the  promontory  of  the  middle 
ear.  Making  the  patient  press  air  into  the  ear  by  a  forced  expiration, 
or,  again,  by  the  fluid  of  the  injection  passing  into  the  throat,  we 
may  judge  of  the  perforated  condition  of  the  membrane.  But  as  it 
often  occurs  in  otorrhoea,  where  the  cavity  of  the  tympanum  is  expo- 
sed, that  the  Eustachian  tube  is  likewise  blocked  up  with  granula- 
tions, or  closed  by  inflammation,  neither  of  those  two  methods  are 
always  applicable.  In  the  latter  case,  injecting  fluid  through  the 
Eustachian  tube  is  likewise  inapplicable.  Wherever  the  granula- 
tions grow  from,  whether  from  the  membrane  itself,  or  from  the  walls 
of  the  tympanum,  the  means  I  find  most  useful  for  their  eradication 
is  the  solid  nitrate  of  silver  rubbed  over  the  part  every  second  day, 
or  oftener,  if  necessary,  with  the  instrument  represented  at  page  293. 

Of  the  many  hundred  cases  of  otorrhoea  which  I  have  examined 
during  the  last  twelve  years,  I  have  never  seen  one  in  which  a  poly- 
pus grew  from  the  surface  of  the  membrana  tympani.  Of  perforation 
of  this  membrane,  from  a  small  aperture  to  its  total  destruction,  as 
well  as  of  the  value  and  mode  of  applying  an  artificial  membrana 
tympani,  or,  rather,  a  substitute  for  that  structure,  I  have  already 
written  at  length  in  the  section  on  that  subject  at  page  287.^ 

'  Since  Chapter  IV.,  alluded  to  above,  went  to  Press,  a  claim  has  been  raised  on  be- 
half of  Mr.  Tod  for  the  discovery  of  a  succedaneum  for  a  lost  or  perforated  inembrane ; 
but  I  see  no  reason  to  alter  what  I  have  already  written  on  the  subject. 


OTORRHffiA. — POLYPUS.  393 


POLYPUS. 


Morbid  growths,  denominated  Polypi,  are  a  frequent  complication 
of  otorrhoea ;  they  may  occur  at  any  period  of  the  discharge ;  as,  after 
otitis  of  a  month's  duration  where  the  membrane  has  been  perforated, 
or  in  the  advanced  stage  of  chronic  catarrhal  inflammation,  with  a 
perfect  membrane,  and  of  many  years'  standing.  They  vary  in  size 
from  that  of  a  small  split-pea  to  such  a  magnitude  as  completely  to 
fill  the  external  auditory  passage,  and  to  project  considerably  from 
the  outer  aperture;  but  at  times  they  are  so  small,  and  lie  so  much 
concealed  in  the  large  anterior  sinus  at  the  bottom  of  the  auditory 
passage,  that  they  may,  with  a  person  not  accustomed  to  aural  ex- 
aminations, escape  detection.  They  are  always  accompanied  by 
discharge,  and  are  frequently  the  chief  source  of  such.  Fleshy, 
pedunculated,  morbid  growths  in  the  ear,  nearly  colorless,  having  a 
thin,  cuticular  covering,  unattended  by  pain,  not  appearing  as  the 
result  of  inflammation,  and  unaccompanied  by  discharge,  are,  in  com- 
parison with  those  to  which  I  have  so  frequently  alluded,  and  am  now 
about  to  describe  in  detail,  extremely  rare.  Throughout  this  essay  I 
have  employed  the  terms  fungus  and  polypus  as  indicative  of  those 
morbid  growths,  the  product  of  inflammatory  action  and  long-con- 
tinued otorrhcea.  By  fungus,  however,  I  particularly  allude  to  those 
vascular  and  granular  masses  which  generally  grow  either  from  dis- 
eased bone,  or  after  the  destruction,  in  whole  or  in  part,  of  the  mem- 
brana  tympani,  and  the  attachments  of  which  are  to  be  found  princi- 
pally at  the  very  bottom  of  the  auditory  passage  in  the  tympanum ; 
while  polypi  are,  for  the  most  part,  confined  to  the  glandular  portion 
of  the  tube,  about  midway  between  the  external  orifice  and  the  mem- 
brana  tympani,  and  are  attached  by  narrower  roots  than  the  fungi. 

In  eight  cases  out  of  a  dozen  these  polypi  sprout  from  the  site  of 
the  cerumenous  glands  in  the  posterior  wall  of  the  meatus ;  they 
generally  grow  singly,  but  I  have,  on  some  rare  occasions,  seen  two 
attached  to  different  parts  of  the  meatus ;  they  may  co-exist  with  a 
granular  state  of  the  membrana  tympani,  or  with  fungous  vegetations 
proceeding  from  the  middle  ear;  sometimes  they  are  pedunculated, 
and  at  others  attached  by  a  large  base.  When  in  cases  of  perforated 
membrane,  a  polypus  springs  from  the  cavity  of  the  tympanum,  and 
passes  through  the  aperture,  it  always  forms  a  nail-like  or  mushroom 
head,  which,  spreading  over  the  outer  sm'face  of  the  membrane,  is  very 


394 


OTORRHCEA.  —  POLYPUS. 


deceptive,  and  gives  the  appearance,  particularly  in  a  long  and  tor- 
tuous meatus,  of  an  open  tympanic  cavity ; — such  growths  can,  how- 
ever, be  always  lifted  off  the  membrane  by  means  of  a  probe  or 
spatula.  These  latter  are,  I  believe,  the  instances  which  authors 
have  mistaken  for  polypi  growing  from  the  surface  of  the  membrana 
tympani  itself.  In  color  polypi  are  generally  a  florid  red,  smooth  and 
polished  on  the  surface  while  still  within  the  meatus,  and  generally 
immersed  in  the  discharge ;  but  as  soon  as  they  appear  externally, — 
and  I  have  seen  them  grow  to  such  an  extent  as  to  mould  themselves 
into  the  concha, — they  become  pale,  cuticular,  and  comparatively  in- 
sensible. Their  sensibility  is  not  very  great  towards  the  free  ex- 
tremity, but  it  always  causes  more  or  less  pain  to  touch  them  at  the 
root.  In  form  they  present  many  varieties,  from  that  of  a  split-pea, 
or  a  small  ovoid  body,  attached  by  a  peduncle  on  its  flat  surface,  to  a 
lobulated  mass,  not  unlike  a  bunch  of  grapes,  and  divisible,  by  deep 
sulci,  into  a  number  of  minor  bodies,  as  shown  in  the  accompany- 
ing illustration  (Figure  23),  which  represents  the  principal  varieties 
of  this  disease,  of  the  full  size. 


Fig.  24. 


Pig.  25. 


Fig.  26 


This  form  of  vegetation  is  always  more  friable  and  gelatinous,  it  is 
generally  of  a  light  pink  or  salmon  color,  and  is  usually  paler  than 
either  the  foregoing  or  the  preceding.  Whether  they  all  proceed 
from  the  same  original  source,  and  present  at  first  the  pea-like  body, 
or  small  globular  mass,  subsequently  modified  according  to  the  con- 
dition of  the  ear,  the  peculiarity  of  the  patient,  or  the  duration  of  the 
disease,  has  still  to  be  determined. 

The  third  form  is  also  lobulated,  as  shown  in  Figure  24 ; 
but  it  is  of  much  firmer  consistence  than  the  second;  the  lobules, 
however,  only  exist  upon  the  surface,  and  resemble  more  the  external 


OTORRHCEA.  —  POLYPUS.  395 

characters  of  a  lobulated  kidney,  or  a  brain, — the  sulci  which  divide 
the  granulations  being  very  shallow.  It  is  generally  of  a  fibrous 
character,  difficult  to  be  cut  through  with  a  wire,  and  has  always  a 
firmly  attached,  extensive  base. 

The  fourth  description,  represented  by  Figui'e  25,  is  also  firm 
and  fibrous  in  its  structure,  though  not  so  much  so  as  the  foregoing, 
from  which  it  differs  by  its  invariably  uniform  surface ;  it  is  seldom 
of  so  florid  a  red  as  in  Figure  24,  but  is  the  third  most  frequent 
kind  which  I  meet  with.  Its  base  is  always  extensive,  and  in  the 
instance  represented,  its  surface  was  traversed  by  several  superficial 
vessels. 

The  fifth  description,  shown  by  Figure  26,  is  a  very  rare  variety 
of  the  disease,  and  may,  from  its  shape,  be  denominated  peari- 
form.  In  the  case  from  which  the  foregoing  illustration  was  made, 
the  globular  extremity  of  the  mass  projected  from  the  external  aper- 
ture, and  was  about  as  florid  as  the  red  border  of  the  lip ;  it  was  also 
dry  and  cuticular,  and  accompanied  with  but  little  discharge ;  it  grew 
from  the  anterior  wall  of  the  meatus,  was  remarkably  tough  and  un- 
yielding, and  came  away  with  its  extensive  base  and  roots,  as  shown 
in  the  engraving. 

All  these  polypi  are  highly  vascular,  but  the  first,  and  to  a  certain 
extent  the  second  also,  are  much  less  so  than  the  others.  The  sixth 
form  of  polypus  is  malignant,  of  which  I  have  given  an  instance  at 
page  205 ;  it  is  of  a  much  more  livid  color,  and,  though  not  friable, 
has  a  peculiar  flabby  feel.  In  each  of  the  cases  which  I  have  seen,  it 
was  remarkably  fetid;  parts  of  it  became  the  color  of  a  ripe  plum, 
sloughed,  and  hemorrhage  followed,  long  before  the  true  maKgnant 
nature  of  the  disease  became  apparent.^ 

'  Mr.  Toynbee,  who  has  written  a  series  of  practical  articles  upon  polypi  of  the  ear 
in  the  Medical  Times  and  Gazette  during  the  course  of  last  year,  divides  these  bodies 
into  the  vascular  polypus,  which  is  "  of  a  red  color,  plentifully  supplied  by  vessels,  and 
so  soft  that,  upon  being  taken  hold  of  by  a  pair  of  dressing  forceps,  it  breaks  up,  and 
blood  escapes  from  the  lacerated  surface.  It  is  composed  of  small  rounded  cells,  and  its 
surface,  which  is  sometimes  covered  by  ciliated  epithelium,  is  very  smooth  and  shining." 
He  also  says,  that  this  form  "  rarely  increases  to  so  large  a  size  as  to  dilate  the  meatus," 
from  which  it  would  appear  that  polypoid  growths  possess  the  power  of  enlarging  the 
calibre  of  that  tube;  but  this  I  do  not  find  they  ever  do  until  they  have  first  completely 
filled  it  and  presented  externally,  when,  their  growth  in  that  direction  being  checked 
by  the  astringent  action  of  the  atmosphere,  they  may,  perhaps,  have  this  effect.  In 
simple  otorrhcea,  however,  when  of  long  standing,  and  accompanied  by  a  thin,  brownish, 
and  ichorous  discharge,  even  without  the  complication  of  polypus,  the  external  meatus 
if  frequently  enlarged,  and  presents  a  ewer-like  mouth.     Mr.  Toynbee's  second  form  is 


396 


OTORRHCEA. 


•POLYPUS. 


Polypi  continue  for  years,  and  seldom  or  never  cure  spontaneously, 
or  by  what  is  termed  "  an  effort  of  nature,"  and  so  long  as  they  exist, 
otorrhoea  will  continue.  From  so  little  having  been  said  about  them 
in  foreign  works,  I  presume  they  are  not  so  common  in  other  coun- 
tries as  in  this ;  as  in  647  cases  of  otorrhoea  enumerated  in  the  table 
at  page  108,  as  many  as  64  were  complicated  with  polypi. 

The  treatment  of  this  disease  consists  in  the  removal  of  the  morbid 
growth ;  the  employment  of  such  measures  as  shall  prevent  revegeta- 
tion, — for  it  is  most  apt  to  return,  and  it  grows  with  great  rapidity, 
— and  in  giving  a  healthy  action  to  the  neighboring  parts.  The 
destruction  of  a  polypus  may  be  accomplished  by  incision  with  either 
a  fine  double-edged  knife,  or  a  curved  slender  scissors,  such  as  those 


here  figured ;  but  this  mode  of  removal  is  only  applicable  to  small 
pedunculated  bodies  near  the  external  margin  of  the  meatus ;  and 
I  now  very  seldom  have  recourse  to  cutting  instruments  of  this 
description. 

For  the  removal  of  polypi  and  other  fungous  growths,  various  me- 
chanical means  have  been  devised,  in  the  shape  of  forceps  and  liga- 
tures, &c.  Without  entering  into  an  historical  description  of  all 
these,  it  is  enough  to  remark,  that  they  were  insufiicient  for  the 
purpose  for  which  they  were  invented ;  the  foriper  instruments  owing 


the  gelatinous  polypus,  a  name  which,  he  says,  "  has  been  given  to  it  from  the  soft  jelly- 
like appearance  presented  by  its  free  portions,  and  from  the  similarity  of  their  general 
aspect  to  the  gelatinous  nasal  polypus,"  which,  as  every  surgeon  is  well  aware,  is  of  a 
grayish  color  and  semitransparent.  The  author  says  that,  when  examined  under  a 
microscope,  "  interspersed  throughout  the  substance  of  the  polypus  were  many  spindle- 
shaped  crystals."  I  cannot  say  that  I  am  acquainted  with  this  variety  of  the  disease, 
nor  have  I  ever  removed  a  polypus  from  the  ear  that  was  not  of  a  red  or  pink  color, 
although  it  became  pale  soon  after  extraction.  The  author's  third  form,  and  which,  he 
says,  has  not  hitherto  attracted  the  attention  of  surgeons,  he  has  styled  "  the  globular 
vascular  polypus;"  this  corresponds  with  that  which  I  have  described  in  Fig.  23,  and  is  the 
most  frequent  form  observed  in  children,  and  as  the  sequel  of  otitis  in  grown  persons. 


OT.ORRHGEA. — POLYPUS.  397 

to  the  brittleness  and  vascularity  of  the  substance  they  were  intended 
to  grasp  ;  and  the  latter  from  the  difficulty  of  applying  them  with 
accuracy  to  the  root  or  foot-stalk  of  the  morbid  growth.  Om'  first 
object  must  be  to  obtain  as  accurate  a  knowledge  as  possible  of  the 
particular  point  from  which  the  polypus  proceeds,  by  passing  a  probe 
or  spatula  round  its  base  ;  when,  if  it  is  of  small  size,  globular  form, 
and  not  very  deeply  seated  within  the  meatus,  as  is  sometimes  the 
case,  it  can  frequently  be  removed  with  the  long  curved  scissors 
(figui-ed  on  the  preceding  page)  half  an  inch  of  the  points  of  which 
alone  are  cutting,  and  the  whole  of  which  measui'es  five  inches ;  or 
by  the  small  double-edged  knife  ;  or  the  curved  one  represented  at 
page  285  ;  all  of  which,  as  well  as  the  toothed  forceps,  can,  when  the 
growth  is  of  small  size  and  fully  exposed,  be  used  with  freedom  and 
effect  through  the  tubular  speculum.  These  instruments  are  figm'od 
a  third  less  than  the  natural  size. 

The  best  instrument  for  the  removal  of  aural  polypus  from  any 
portion  of  the  meatus  is  the  small  snare-like  apparatus  here  repre- 
sented, consisting  of  a  fine  steel  stem,  five  inches  long,  and  bent  in 

Fig.  2S, 


the  centre,  for  the  reasons  explained  at  page  67 ;  with  a  movable 
bar  shding  on  the  square  portion  near  the  handle,  which  latter  part 
fits  over  the  thumb,  as  shown  in  the  cut.^  The  upper  extremity  is 
perforated  with  holes  running  parallel  with  the  stem ;  and  loops  at 
the  angle  serve  the  same  purpose.  A  fine  wire,  fastened  to  the  cross 
bar,  passes  through  these  loops  and  holes ;  it  should  be  of  such  a 
length  that,  when  the  cross  bar  is  drawn  up  tight  to  handle,  the  liga- 
tm*e  is  fully  on  the  stretch.     Having  tried  wires  of  different  materials, 

*  For  the  history  of  this  instrument,  see  the  author's  Essay  upon  the  Causes  and 
Treatment  of  Otorrhcea,  page  52 ;  and  also  that  upon  the  Inflammatory  Affections  of  the 
Membrana  Tympani  and  Middle  Ear,  page  10, — both  referred  to  at  page  62  of  this 
work.  This  snare  removes  gelatinous  polypi  from  the  nose  with  much  greater  facility, 
and  with  very  much  less  pain  and  injury  to  the  parts,  than  the  ordinary  forceps  used 
for  that  purpose. 


398  OTORRHCEA.  —  POLYPUS. 

— silver  and  platina,  and  of  various  degrees  of  strength  and  flexi- 
bility, I  have  found  that  fine  steel  wire  of  No.  24  grist,  with  the 
temper  taken  out  of  it  by  heat,  is  far  the  toughest,  most  flexible,  and 
least  apt  to  cut.  In  making  this  instrument,  the  loops  at  the  side 
and  the  holes  at  the  top  should  be  very  smooth,  and  their  edges 
bevelled  ofi",  so  that  the  wire  will  not  scrape  or  cut  in  running  through 
them.  The  thumb  piece  and  cross  bar  may  be  formed  of  German 
silver.  In  using  it  the  cross  bar  is  pushed  forward,  and  a  noose  made 
of  the  wire  at  the  small  extremity,  of  sufficient  size  to  include  the 
morbid  growth,  which  it  is  then  made  to  surround,  and  towards  the  root 
of  which  it  is  pressed  by  means  of  the  stem ;  the  cross  bar  is  then 
drawn  up  smartly  to  the  handle,  while  the  point  of  the  stem  is  pressed 
downwards ;  and  it  never  fails  of  either  cutting  across  or  of  drawing 
with  it  whatever  was  included  in  the  noose.  Bleeding  generally  fol- 
lows, upon  the  subsidence  of  which  we  should  syringe  the  canal  with 
tepid  water,  and  again  examine  the  ear,  and  if  possible  discover  what 
portion  of  the  polypus  may  remain,  which,  whether  it  be  the  mere 
point  of  attachment,  or  a  portion  inaccessible  to  instruments,  should 
be  touched  with  the  armed  porte-caustic,  and  the  same  application 
applied  from  day  to  day  until  all  traces  of  the  morbid  growth  have 
vanished.  Unless  this  latter  point  of  practice  be  strictly  and  perse- 
veringly  adhered  to,  it  is  in  vain  that  we  can  expect  a  total  eradica- 
tion of  the  disease ;  no  more,  however,  of  the  auditory  apparatus 
should  be  submitted  to  the  action  of  the  caustic  than  the  actual 
granulating  or  fungous  surface.  I  have  frequently  seen  the  whole 
canal  in  a  state  of  ulceration,  and  an  erysipelatous  inflammation 
extending  over  the  entire  auricle,  from  a  stick  of  lunar  caustic  having 
been  inserted  and  rolled  round  in  the  meatus  to  remove  a  polypus  or 
fungous  growth,  the  eradication  of  which  had  already  been  frequently 
attempted  by  instruments  ;  a  practice  as  cruel^as  it  was  ineffectual. 

Some  practitioners  prefer  the  potassa  fusa  and  various  other  caus- 
tics for  the  removal  of  these  growths ;  but,  with  respect  to  these  and 
all  other  remedies  of  a  like  character,  I  can  only  say,  that  after  a 
very  extensive  trial  during  many  years  of  the  snare  and.  the  solid 
nitrate  of  silver,  I  have  never  found  them  to  fail  in  eradicating  polypi, 
no  matter  of  what  description. 

Dr.  Evory  Kennedy,  in  his  paper  upon  uterine  diseases,^  recom- 
mends the  use  of  the  nitrate  of  mercury  in  the  treatment  of  polypoid 

'  See  Dublin  Quarterly  Journal  of  Medical  Science  for  February,  1847. 


OTORRHCEA. CARIES.  399 

growths  and  ulcerations  of  the  os  uteri ;  but  my  experience  of  all  such 
applications  to  the  ear  is,  that  they  are  too  deliquescent,  and  their 
action  cannot  always  be  limited.  Astringent  lotions  will  not  cure 
aural  polypi. 

CARIES. 

The  third  and  most  frequent  complication  and  consequence  of  otor- 
rhoea  is  caries.  Necrosis  of  the  bony  case  of  the  ear  is  not  an  unfre- 
quent,  and  is  always  a  dangerous  attendant  upon,  or  a  source  of,  aural 
discharge,  but  here  a  doubt  arises  as  to  what  the  original  disease  was, 
— whether  it  proceeded  from  otitis,  spreading  to  the  periosteum,  and 
thence  to  the  bone, — or  from  inflammation  of  the  mucous  membrane 
extending  from  the  drum  into  the  mastoid  cells.  This  latter  mode  is 
what  I  believe  frequently  takes  place  in  those  cases  when,  after  the 
continuance  of  otorrhoea,  the  mastoid  process  comes  away ;  and  there 
are  several  pathological  specimens  which  tend  to  confirm  this  view. 

Instances  of  the  loss  of  the  whole  or  a  portion  of  the  mastoid  pro- 
cess are  by  no  means  uncommon ;  the  preparation  represented  in  the 
accompanying  woodcut,  and  which  forms  the 
entire  bulk  of  the  mastoid  process,  a  large  ^^'  ^^" 

piece  of  the  petrous  portion  of  the  temporal 
bone,  including  the  posterior  wall  of  the  mid- 
dle ear,  and  one  of  the  semicircular  canals, 
was  removed  in  my  presence  from  a  child 
three  years  of  age,  by  Mr.  Cusack,  in  the 
Dispensary  of  Steevens'  Hospital,  in  the  year 
1833.     Having  had  charge  of  that  case  for  a 

considerable  time  subsequently,  my  attention  was  then  first  called  in 
an  especial  manner  to  aural  afiections.  Cases  of  this  description, 
however,  the  result  of  extension  of  disease  from  the  meatus  and 
middle  ear,  are  not  to  be  confounded  with  inflammation  of  the  peri- 
osteum of  the  mastoid  process,  occurring  idiosynchronously,  nor  of 
abscess  taking  place  underneath  it,  nor  between  the  dura  mater  and 
the  bone,  upon  a  corresponding  portion  of  the  internal  surface  of  the 
cranium. 

The  splendid  pathological  collection  of  the  Richmond  Hospital,  in 
this  city,  contains  five  most  interesting  and  valuable  preparations  of 
disease  of  the  temporal  bone,  and  one  of  these  is  in  exact  accordance 
with  the  view  which  I  have  expressed  above.     The  subject  of  this 


400  OTORRHCEA.  —  CARIES. 

affection,  aged  16,  was  idiotic,  and  nearly  deaf  and  dumb.  For  some 
months  previous  to  her  death  she  had  pain  in  and  semi-purulent  dis- 
charge from  both  ears,  and  was  also  frequently  attacked  with  fits  of 
epilepsy.  Death  took  place  suddenly.  Professor  Smith,  who  laid 
the  case  before  the  Pathological  Society,  stated,  that  on  the  right 
side,  the  membrana  tympani,  the  malleus,  stapes,  and  incus  were  all 
destroyed,  and  the  mastoid  cells  contained  purulent  matter.  "  The 
left  side  presented  a  very  remarkable  specimen  of  disease  of  the 
mastoid  and  petrous  portions  of  the  temporal  bone.  Above  the 
meatus  the  temporal  bone  was  perforated  by  a  large  opening,  which 
communicated  on  one  side  with  the  cavity  of  the  tympanum,  and  on 
the  other  with  the  mastoid  cells.  All  the  partitions  of  the  mastoid 
cells  were  destroyed,  and  the  whole  cavity  thus  formed  was  filled 
with  fetid  pus,  mixed  with  particles  of  carious  bone.  The  purulent 
matter  had  also  penetrated  into  the  vestibule,  the  cochlea,  and  the 
aqueduct  of  Fallopius.  The  foramen  rotundum,  and  fenestra  ovalis, 
were  thrown  into  one  large  opening.  On  tracing  the  nerves,  it  was 
found  that  the  portio  dura,  where  it  passes  through  the  aqueduct  of 
Fallopius,  was  covered  with  lymph  and  purulent  matter  of  a  greenish 
hue.  The  dura  mater  covering  the  anterior  surface  of  the  petrous 
portion  of  the  temporal  bone,  was  slightly  discolored,  but  there  was 
no  pus  in  the  vicinity.  The  great  lateral  sinus  upon  the  same  side 
presented  the  appearance  of  commencing  inflammation ;  the  lining 
membrane  was  of  a  dark-green  color,  and  the  blood  in  the  sinus  was 
coagulated.  There  was  in  this  case  no  paralysis  or  distortion  of  the 
face." 

Had  injections  been  used  in  this  case,  or  had  art  interfered  with  it 
in  any  way,  and  had  no  examination  been  made  after  death,  it  would, 
among  the  disciples  of  Itard,  have  been  set  down  as  one  manifesting 
the  deleterious  effects  of  stimulating  applications ;  or,  had  even  milk 
been  injected,  it  would,  as  well  as  the  linseed  oil  already  referred  to, 
have  been  forthwith  expunged  the  aurist's  pharmacopoeia. 

Instances  of  caries  of  the  temporal  bones  producing  death,  as  the 
effects  of  otorrhoea,  might  be  multiplied  without  end.  The  prepara- 
tions in  the  Richmond  Museum  exhibit  the  process  of  the  inflamma- 
tion, death,  and  separation  of  the  bone  in  its  various  stages,  all  sooner 
or  later  affecting  the  head.  In  these,  and  I  am  led  to  believe  in  the 
great  majority  of  other  instances  also,  the  destructive  process  had 
proceeded  from  without  inwards,  and  what  was  originally  an  otor- 


OTORRHCEA.  —  CARIES.  401 

rhoea  from  an  inflamed  mucous  and  periosteal  membrane  spread  from 
thence  to  the  bone  itself. 

A  very,  remarkable  case  of  otorrhoea  and  death  caused  by  caries  of 
the  petrous  portion  of  the  temporal  bone,  has  been  recorded  by  the 
late  Dr.  Graves.^  The  subject  of  it  was  a  scrofulous  boy,  ten  years 
of  age,  who  was  admitted  into  hospital  for  dropsy  and  diarrhoea,  of 
which  he  was  relieved — "  when  it  was  observed  that  there  was  paraly- 
sis of  the  right  side  of  the  face,  but  obvious  only  when  the  muscles  of 
the  face  were  in  action.  Thus  the  attempt  to  close  the  eye  failed  on 
the  affected  side.  There  was  a  discharge  from  the  ear  of  the  same 
side,  which  originated  seven  years  previously .  The  opinion  formed 
of  the  case  was,  that  there  was  disease  of  the  petrous  portion  of  the 
temporal  bone,  and  that  with  this  was  connected  the  affection  of  the 
portia  dm'a  of  the  seventh  pair,  from  which  the  paralysis  might  be 
considered  to  result.  There  was  pain  in  the  head  to  the  right  side, 
which  after  some  time  changed  its  place,  and  moved  to  the  back  of 
the  head,  and  from  this  time  the  discharge  from  the  ear  ceased.  The 
pain  then  moved  down  the  spine.  A  few  days  before  death  there 
were  tetanic  con^oilsions,  and  an  extreme  sensibility  of  the  entire  sm'- 
face  of  the  body.  Three  years  before  there  had  been  similar  convul- 
sions. The  power  of  locomotion  and  the  intellect  continued  to  the 
last  unimpaired.  Dm-ing  the  few  days  which  intervened  between  the 
first  appearance  of  the  con^nilsions,  and  his  death,  they  had  recurred 
five  or  six  times.  The  body  was  examined  after  death.  Within  the 
skull  a  perforation  was  observed  in  the  dura  mater,  immediately  op- 
posite to  the  aqueduct  of  the  vestibule,  in  the  petrous  portion  of  the 
temjjoral  bone,  which  was  carious.  A  green  fetid  pus  detached  the 
dura  mater  from  the  bone  in  this  situation,  and  also  bathed  the  nerves 
at  the  base  of  the  brain.  The  membrana  tympani  and  internal  ear 
had  been  destroyed.  The  brain  itself  appeared  healthy.  The  theca 
of  the  medulla  spinalis  was  filled  with  pus,  but  the  medulla  itself  (of 
which  Dr.  Graves  exhibited  a  drawing)  appeared  healthy,  and  the 
attachments  of  the  ligamentum  dentatum  were  all  perfect." 

There  can,  I  think,  be  little  doubt  but  that  the  caries  in  this  instance 
was  a  secondary  affection,  arising  from  extension  of  the  original  otitis, 

'  It  is  with  heartfelt  sorrow  I  have  now  to  speak  and  write  of  Dr.  Graves  in  the  past 
tense.  Since  my  previous  notice  of  this  distinguished  physician,  the  science  of  medi- 
cine at  large,  and  the  Irish  nation  in  particular,  have  experienced  a  loss  which  is  not 
likely  to  be  replaced  in  the  lifetime  of  the  present  generation ;  and  the  author  has  been 
deprived  by  death  of  one  of  his  earliest,  firmest,  and  best  of  friends. 

26 


400  OTORRHCEA.  —  CARIES. 

affection,  aged  16,  was  idiotic,  and  nearly  deaf  and  dumb.  For  some 
months  previous  to  her  death  she  had  pain  in  and  semi-purulent  dis- 
charge from  both  ears,  and  was  also  frequently  attacked  with  fits  of 
epilepsy.  Death  took  place  suddenly.  Professor  Smith,  who  laid 
the  case  before  the  Pathological  Society,  stated,  that  on  the  right 
side,  the  membrana  tympani,  the  malleus,  stapes,  and  incus  were  all 
destroyed,  and  the  mastoid  cells  contained  purulent  matter.  "  The 
left  side  presented  a  very  remarkable  specimen  of  disease  of  the 
mastoid  and  petrous  portions  of  the  temporal  bone.  Above  the 
meatus  the  temporal  bone  was  perforated  by  a  large  opening,  which 
communicated  on  one  side  with  the  cavity  of  the  tympanum,  and  on 
the  other  with  the  mastoid  cells.  All  the  partitions  of  the  mastoid 
cells  were  destroyed,  and  the  whole  cavity  thus  formed  was  filled 
with  fetid  pus,  mixed  with  particles  of  carious  bone.  The  purulent 
matter  had  also  penetrated  into  the  vestibule,  the  cochlea,  and  the 
aqueduct  of  Fallopius.  The  foramen  rotundum,  and  fenestra  ovalis, 
were  thrown  into  one  large  opening.  On  tracing  the  nerves,  it  was 
found  that  the  portio  dura,  where  it  passes  through  the  aqueduct  of 
Fallopius,  was  covered  with  lymph  and  purulent  matter  of  a  greenish 
hue.  The  dura  mater  covering  the  anterior  surface  of  the  petrous 
portion  of  the  temporal  bone,  was  slightly  discolored,  but  there  was 
no  pus  in  the  vicinity.  The  great  lateral  sinus  upon  the  same  side 
presented  the  appearance  of  commencing  inflammation ;  the  lining 
membrane  was  of  a  dark-green  color,  and  the  blood  in  the  sinus  was 
coagulated.  There  was  in  this  case  no  paralysis  or  distortion  of  the 
face." 

Had  injections  been  used  in  this  case,  or  had  art  interfered  with  it 
in  any  way,  and  had  no  examination  been  made  after  death,  it  would, 
among  the  disciples  of  Itard,  have  been  set  down  as  one  manifesting 
the  deleterious  effects  of  stimulating  applications ;  or,  had  even  milk 
been  injected,  it  would,  as  well  as  the  linseed  oil  already  referred  to, 
have  been  forthwith  expunged  the  aurist's  pharmacopoeia. 

Instances  of  caries  of  the  temporal  bones  producing  death,  as  the 
effects  of  otorrhoea,  might  be  multiplied  without  end.  The  prepara- 
tions in  the  Richmond  Museum  exhibit  the  process  of  the  inflamma- 
tion, death,  and  separation  of  the  bone  in  its  various  stages,  all  sooner 
or  later  affecting  the  head.  In  these,  and  I  am  led  to  believe  in  the 
great  majority  of  other  instances  also,  the  destructive  process  had 
proceeded  from  without  inwards,  and  what  was  originally  an  otor- 


OTORRHOSA.  —  CARIES.  401 

rhoea  from  an  inflamed  mucous  and  periosteal  memlbrane  spread  from 
thence  to  the  bone  itself. 

A  very,  remarkable  case  of  otorrhoea  and  death  caused  by  caries  of 
the  petrous  portion  of  the  temporal  bone,  has  been  recorded  by  the 
late  Dr.  Graves.^  The  subject  of  it  was  a  scrofulous  boy,  ten  years 
of  age,  who  was  admitted  into  hospital  for  dropsy  and  diarrhoea,  of 
which  he  was  relieved — "  when  it  was  observed  that  there  was  paraly- 
sis of  the  right  side  of  the  face,  but  obvious  only  when  the  muscles  of 
the  face  were  in  action.  Thus  the  attempt  to  close  the  eye  failed  on 
the  affected  side.  There  was  a  discharge  from  the  ear  of  the  same 
side,  which  originated  seven  years  previously .  The  opinion  formed 
of  the  case  was,  that  there  was  disease  of  the  petrous  portion  of  the 
temporal  bone,  and  that  with  this  was  connected  the  affection  of  the 
portia  dui'a  of  the  seventh  pair,  from  which  the  paralysis  might  be 
considered  to  result.  There  was  pain  in  the  head  to  the  right  side, 
which  after  some  time  changed  its  place,  and  moved  to  the  back  of 
the  head,  and  from  this  time  the  discharge  from  the  ear  ceased.  The 
pain  then  moved  down  the  spine.  A  few  days  before  death  there 
were  tetanic  convulsions,  and  an  extreme  sensibility  of  the  entire  sur- 
face of  the  body.  Three  years  before  there  had  been  similar  convul- 
sions. The  power  of  locomotion  and  the  intellect  continued  to  the 
last  unimpaired.  During  the  few  days  which  intervened  between  the 
first  appearance  of  the  convulsions,  and  his  death,  they  had  recurred 
five  or  six  times.  The  body  was  examined  after  death.  Within  the 
skull  a  perforation  was  observed  in  the  dura  mater,  immediately  op- 
posite to  the  aqueduct  of  the  vestibule,  in  the  petrous  portion  of  the 
temporal  bone,  which  was  carious.  A  green  fetid  pus  detached  the 
dura  mater  from  the  bone  in  this  situation,  and  also  bathed  the  nerves 
at  the  base  of  the  brain.  The  membrana  tympani  and  internal  ear 
had  been  destroyed.  The  brain  itself  appeared  healthy.  The  theca 
of  the  medulla  spinalis  was  filled  with  pus,  but  the  medulla  itself  (of 
which  Dr.  Graves  exhibited  a  drawing)  appeared  healthy,  and  the 
attachments  of  the  ligamentum  dentatum  were  all  perfect." 

There  can,  I  think,  be  little  doubt  but  that  the  caries  in  this  instance 
was  a  secondary  affection,  arising  from  extension  of  the  original  otitis, 

^  It  is  with  heartfelt  sorrow  I  have  now  to  speak  and  write  of  Dr.  Graves  in  the  past 
tense.  Since  my  previous  notice  of  this  distinguished  physician,  the  science  of  medi- 
cine at  large,  and  the  Irish  nation  in  particular,  have  experienced  a  loss  which  is  not 
likely  to.  be  replaced  in  the  lifetime  of  the  present  generation ;  and  the  author  has  been 
deprived  by  death  of  one  of  his  earliest,  firmest,  and  best  of  friends. 

26 


402  OTORRH(EA.  —  FACIAL    PARALYSIS. 

and  had  that  disease  been  properly  treated  at  the  commencement,  it 
is  more  than  probable  that  the  caries  would  never  have  supervened. 
From  this  case  we  also  learn  how,  when  dangerous  symptoms  follow, 
the  discharge  ceased,  not  from  any  metastasis,  but  in  all  probability 
by  the  matter  not  finding  a  ready  outlet  through  the  carious  portion 
of  the  temporal  bone,  having  fallen  into  the  theca  vertebralis,  and 
pressed  upon  the  spinal  marrow ;  and  this  accounts  likewise  for  the 
removal  of  the  pain  to  the  back  of  the  head  and  down  the  spine,  as 
detailed  above.  In  the  case  related,  fortunately  for  the  cause  of 
aural  surgery,  injections  were  not  had  recourse  to.  I  have  given  an 
instance  of  caries  of  the  internal  ear  at  page  358. 

LESION   OP   THE   FACIAL   NERVE. 

Facial  paralysis  is  a  frequent  result  of  otorrhoea  and  caries  of  the 
temporal  bone,  and  is,  I  have  reason  to  believe,  produced  by  absolute 
lesion  of  the  portio  dura,  from  ulceration  extending  through  the 
diseased,  aqueduct  of  Fallopius.  This  form  must  be  carefully  distin- 
guished from  inflammation  extending  to  the  neurilemma,  and  perhaps 
the  nerve  itself,  from  otitis  or  myringitis,  as  I  have  shown  at  page 
331.  Mr.  Hamilton,  of  this  city,  has  recorded  one  of  the  best- 
marked  cases  of  actual  division  of  the  facial  nerve  by  extension  of 
disease  from  the  temporal  bone.  The  patient,  a  man  aged  55,  had 
otorrhoea  with  paralysis  of  the  right  side  of  the  face  and  difficulty  of 
deglutition.  He  died  apparently  from  disease  of  the  brain ;  and  the 
post  mortem  examination  showed  extensive  inflammation  of  that 
viscus  and  its  investments.  The  petrous  bone  presented  the  usual 
greenish  color  on  the  inner  surface ;  it  was  also  carious,  and  its  struc- 
ture infiltrated  with  fetid  pus.  The  facial  nerve  could  be  traced  from 
the  internal  meatus  to  the  carious  part  of  the  bone,  where  it  ended, 
and  there  was  a  deficiency  between  it  and  the  lower  portion,  to  the 
extent  of  one-eighth  of  an  inch.  "  The  nerve  could  be  traced  from 
the  meatus  internus  to  the  carious  part  of  the  bone,  where  it  ended ; 
and  in  like  manner  it  could  be  traced  from  the  stylo-mastoid  foramen 
up  the  Fallopian  canal  to  the  situation  of  the  caries,  where  all  traces 
of  its  original  structure  were  lost.  There  was  a  difierence  between 
the  two  portions  of  the  nerve  ;  the  upper  portion  was  more  vascular, 
and  ended  in  a  small  bulb ;  the  lower  portion  was  pale,  and  apparently 
natural."^ 

1  Proceedings  of  the  Pathological  Society,  in  the  Dublin  Journal  of  Medical  Science 
for  July,  1841,  pp.  458  and  472. 


OTORRHCEA.  —  CEREBRAL    AFFECTIONS.  403 

In  some  rare  instances  of  double  otorrlicea,  facial  pai^alysis  occurs 
on  hath  sides,  then  the  appearance  of  the  patient  is  truly  remark- 
able :  there  is  a  preternatural  fulness  of  both  cheeks,  a  droop  in  both 
loAver  eyelids,  and  also  in  the  external  angles  of  the  mouth ;  but  the 
most  singular  appearance  is  an  unusually  vacant  stare  and  inexpres- 
sive character  of  the  whole  countenance.  A  case  of  this  nature  has 
been  recently  afforded  me  by  Dr.  Frazer.  The  patient,  nine  years 
of  age,  had  morbus  cox^e  for  some  years,  when  strumous  otorrhoea 
occurred  on  both  sides,  attended  subsequently  with  paralysis  of  one 
side  of  the  face,  and  in  some  time  afterwards  the  other  side  became 
similarly  affected :  "  The  double  paralysis  produced  a  remarkable 
absence  of  all  expression  in  the  face :  the  features,  which  were  before 
extremely  intelligent,  resembling  very  much  those  of  a  much  older 
person  in  a  state  of  complete  repose.  The  masseters  and  pterygoids 
were  not  affected.     He  finally  died  of  cerebral  disease." 

CEREBRAL   AFFECTIONS    CONSEQUENT    UPON    OTORRHCEA. 

Under  the  head  of  "cerebral  otorrhoea,"  head  affections  consequent 
on  discharge  from  the  ear,  extension  of  inflammation  and  caries  of 
the  temporal  bone,  and  metastasis  of  aural  affections  to  the  brain  and 
its  membranes-, — the  profession  has  been  well  acquainted  for  several 
years  past  with  one  of  the  most  fatal  results  of  this  disease.  Cases 
illustrative  of  this  question  have  been  accumulating  from  year  to  year 
since  the  writings  of  Abercrombie  and  Lallemand,  &c.,  appeared ; 
and  the  Transactions  of  the  Pathological  Society  of  Dublin^  record 
many  instructive  cases  which  bear  upon  this  subject,  with  which,  as 
may  naturally  be  expected,  I  am  familiar. 

Mr.  Toynbee,  in  a  communication  recently  made  to  the  Medico- 
Chirurgical  Society  of  London,  upon  the  affections  of  the  ear  which 
produce  diseases  of  the  brain,  and  to  which  I  have  already  drawn  at- 
tention at  page  197,  has,  with  the  exception  of  those  above  alluded 
to,  tabulated  the  various  cases  related  in  medical  or  surgical  records.^ 
I  may,  however,  be  excused  remarking,  in  connexion  with  this  sub- 

'  It  is  much  to  be  regretted  that  the  Pathological  Society  of  Dublin  have  not  pub- 
lished their  valuable  Transactions  separately  ;  as,  until  they  do,  the  materials  contained 
in  their  vi^eekly  numbers,  although  preserved  in  one  of  our  periodicals,  is,  to  a  certain 
extent,  inaccessible  to  the  profession. 

^  Mr.  Toynbee  had  added  to  his  former  communication  a  paper  "  On  Diseases  of  the 
Internal  Ear,  extending,  through  the  medium  of  the  auditory  nerve,  to  the  medulla 
oblongata  and  base  of  the  brain,'"  in  the  London  Journal  of  Medicine  for  August,  1852. 


404  OTOREHCEA.  —  CEREBRAL    AFFECTIONS. 

ject,  that  I  had  previously  drawn  attention  to  the  subject  in  January, 
1844,  and  related  some  of  the  cases  which  had  then  occurred  in  this 
country.  That  caries  of  particular  portions  of  the  bony  case  of  the 
ear  may  give  rise  to  disease  in  special  parts  of  the  brain,  or  its  mem- 
branes or  the  cerebral  sinuses,  I  do  not  deny ;  but  I  must  confess 
that  as  yet  the  details  of  cases  are  not  sufficiently  conclusive  to  enable 
me  to  decide  with  certainty  on  this  fact ;  and  of  this  any  one  can 
judge  who  will  carefully  examine  the  Table  given  in  the  Medico-Chi- 
rurgical  Transactions. 

A  case  of  otorrhoea  may  continue  for  years  without  causing  greater 
inconvenience  than  the  loss  of  hearing  and  the  pollution  from  the  dis- 
charge ;  the  patient,  however,  becomes  suddenly  unwell ;  he  gene- 
rally has  a  shivering  which  is  attributed  to  cold ;  and  after  that  irri- 
tative fever  sets  in,  pain  is  experienced  deep  in  the  ear  and  over  the 
side  of  the  head ;  and  in  some  cases,  but  not  all,  a  soreness  is  felt  on 
pressing  the  mastoid  region  or  anywhere  around  the  attachment  of 
the  auricle.  The  patient  takes  to  bed  ;  sleeplessness  is  almost  inva- 
riably experienced  ;  incessant  delirium  follows,  from  which,  however, 
the  patient  can  be  roused  and  induced  to  answer  questions  rationally; 
there  is  always  present  a  weight  in  the  head,  the  person  does  not  like 
to  be  disturbed,  and  shows  great  disinclination  to  be  lifted  into  a 
semi-erect  posture.  Erom  about  the  period  of  the  commencement  of 
the  attack  the  discharge  from  the  ear  generally  lessens,  but  seldom 
altogether  ceases ;  and  I  have  in  some  cases  seen  it  continue  through- 
out the  disease  as  profuse  as  ever.  Fresh  rigors  ensue,  characterized 
by  nervous  symptoms  of  a  peculiar  character :  such  as  unconscious- 
ness, strabismus,  and  even  convulsions,  subsequently  all  the  symptoms 
of  inflammation,  effusion,  and  suppuration  within  the  cranium,  super- 
vene. The  train  of  nervous  symptoms  which  follow  are  often  ano- 
malous ;  and  the  paralytic  affections  which  succeed  are  of  an  extra- 
ordinary character,  and  can  with  difficulty  be  explained  according  to 
our  present  notions  of  the  physiology  of  the  brain  and  spinal  marrow. 
Daily  rigors,  convulsions,  coma,  and  death,  sooner  or  later  close  the 
scene.  The  course  of  the  disease  is,  however,  very  various ;  by  the 
prompt  application  of  remedies — mercury  internally,  local  depletion 
and  counter-irritation  externally,  and  by  a  free  incision,  timely  made 
over  the  painful  spot,  when  such  presents  over  the  mastoid  process 
or  elsewhere — I  have  seen  the  disease  arrested ;  but  more  frequently 
■the  relief  is  only  temporary ;  and  this  insidious  affection  proceeds 


OTORRHCEA.  —  CEREBRAL    AFFECTIONS.  405 

with  a  slow,  latent  course,  even  after  an  apparent  convalescence,  to  a 
fatal  termination. 

Upon  examination  after  death  it  will  be  found  that  the  dura  mater 
has  been  separated,  to  a  certain  extent,  from  the  petrous  portion  of 
the  temporal  bone,  and  that  the  space  so  caused  is  filled  with  green- 
ish serum,  while  the  bone  itself,  at  that  spot,  is  of  a  dark  greenish 
hue,  but  still  unbroken.  The  bone,  may,  however,  have  been  carious, 
and  the  head  symptoms  may  have  resulted  from  diffused  inflamma- 
tion of  the  membranes  of  the  brain,  or  abscess  in  the  cerebrum  or 
cerebellum. 

These  cerebral  symptoms  do  not,  however,  in  every  case,  appear  to 
be  the  immediate  cause  of  death.  I  remember  two  cases  in  particu- 
lar, and  I  suppose  they  are  the  types  of  many  others  of  the  same 
class,  where  the  lungs  became  affected  in  the  latter  stage  of  the  dis- 
ease, and  in  which  the  thoracic  affection  seemed  to  be  the  immediate 
cause  of  dissolution.  In  both,  considerable  swelling  of  the  neck  oc- 
cmred  along  the  course  of  the  mastoid  muscle,  extending  from  the  ear 
to  the  clavicle ;  in  one  of  these,  which  I  attended  along  with  Mr.  Cu- 
sack  and  Dr.  Stokes  some  years  ago,  a  large  abscess  formed  over  the 
site  of  the  jugular,  and  the  patient  died  of  mortification  of  the  lung  ; 
in  that  instance  the  fetor  from  the  breath  was  most  intolerable.  In 
the  other  case  which  I  attended,  within  the  last  month,  along  with 
Mr.  Cusack  and  Dr.  Newland,  there  was,  from  the  first,  considerable 
swelling  over  the  side  of  the  neck,  extending  from  the  post-aural  and 
occipital  region  to  the  clavicle ;  the  patient  died  apparently  from  the 
pulmonary  affection,  and  with  the  same  fetor  of  the  breath  as  that 
already  alluded  to.  In  such  cases  I  am  inclined  to  think  that  the 
disease  of  the  j)etrous  bone  extends  to  the  lateral  sinus,  and  induces 
purulent  infection  of  the  venous  system,  which  eventuates  in  disease 
of  the  lung.  A  similar  case,  bearing  out  the  pathology  of  this  affec- 
tion, was  laid  before  our  Pathological  Society  by  Professor  Smith  in 
1840.  A  boy,  aged  16,  had  otorrhoea,  and  in  process  of  time  head 
symptoms  set  in.  He  had  shiverings,  uncertainness  of  gait,  vertigo, 
dilated  pupils,  nausea,  pulse  132,  and  pain  in  his  right  ear  and  in  the 
back  of  his  head.  After  admission  into  hospital  he  slept  but  little, 
had  frequent  startings,  moaning,  and  complaining  of  acute  pain  in  the 
ear, — "  whenever  he  attempted  to  rise  he  supported  his  head  with  his 
hand,"  which  latter  symptom  of  a  feeling  of  weight  and  a  dislike  to 
to  move  the  head  is  an  invariable  attendant  upon  cerebral  symptoms 
consequent  upon  otorrhoea.     An  incision  was  made  over  the  mastoid 


406  OTORRIKEA. — CEREBRAL    AFFECTIONS. 

process,  when  a  little  fetid  matter  was  given  exit  to,  and  the  hone  was 
found  denuded.  He  subsequently  became  jaundiced,  and  "  had  like- 
wise cough,  which  was  very  distressing,  accompanied  by  severe  pain 
along  the  right  side  of  the  neck."  He  died  comatose  eight  days  after- 
wards. The  membranes  of  the  brain  were  injected  with  blood,  espe- 
cially along  the  inferior  surface.  Three  small  purulent  deposits  were 
found  at  the  inferior  surface  of  the  right  lobe  of  the  cerebellum,  where 
it  corresponded  to  the  lateral  sinus ;  the  dura  mater  was  separated  by 
pus  and  lymph  of  a  green  color  from  the  anterior  surface  of  the  pe- 
trous bone ;  there  was  no  perforation  of  the  membrane,  but  over  that 
portion  of  the  bone  which  constitutes  the  superior  wall  of  the  tym- 
panum it  was  elevated  into  a  small  tumor  by  a  collection  of  fetid  mat- 
ter, and  presented  a  sloughy  aspect.  The  portion  of  bone  corre- 
sponding to  this  abscess,  for  about  one-fourth  of  an  inch  in  diameter, 
was  dead,  and  of  a  dull  white  color.  The  process  of  separation  was 
at  one  point  complete,  the  aperture  thus  formed  communicating  with 
the  cavity  of  the  tympanum ;  the  remainder  of  the  bone  was  remark- 
able for  its  vascularity.  The  membrana  tympani  had  disappeared 
altogether  ;  the  membranous  walls  of  the  right  lateral  sinus,  through- 
out the  whole  of  the  mastoid  portion  of  its  course,  were  much  thick- 
ened, and  their  lining  "  presented  a  sloughy  appearance,  being  covered 
with  lymph  of  a  greenish  hue,  and  smeared  with  an  unhealthy,  puru- 
lent matter.  This  condition  of  the  lining  membrane  extended  along 
the  jugular  vein  and  superior  vena  cava  to  within  a  short  distance  of 
the  entrance  of  the  latter  into  the  auricle ;  the  lining  membrane  of  the 
remainder  of  the  vena  cava  was  of  a  dull  tawny  color."  The  thorax 
was  carefully  examined,  and  the  following  appearances  noted  : — "The 
left  cavity  of  the  pleura  contained  about  four  ounces  of  thin  fetid 
matter,  and  a  yellow  tenacious  lymph  adhered  both  to  the  costal  and 
pulmonary  layers  of  the  membrane.  Similar  appearances  were  no- 
ticed in  the  right  cavity  of  the  pleura,  but  not  to  the  same  extent ; 
the  lungs  were  solidified  in  the  postero-inferior  portions,  and  small  cir- 
cumscribed deposits  of  purulent  matter  were  scattered  through  them ; 
these  deposits  were  contained  in  cavities  lined  by  a  smooth  membrane, 
and  in  two  intances  a  small  branch  of  a  vein  was  distinctly  traced 
opening  into  them  ;  these  veins  were  inflamed ;  lymph  was  deposited 
upon  their  exterior,  and  purulent  matter  was  contained  within  them  ; 
there  also  existed  in  the  left  lung  three  large  spots,  resembling  pul- 
monary apoplexy  ;  these  were  as  large  as  a  walnut,  firm,  of  a  livid 
blue  color,  and  blood  exuded  from  them  upon  pressure ;  the  lining 


OTORRHGEA.  —  CEREBRAL    AFFECTIONS.  407 

membrane  of  the  smaller  broncliial  tubes  was  intensely  vascular,  the 
pericardium  contained  about  three  ounces  of  serum,  and  flocculi  of 
lymph  were  seen  upon  the  surface  of  the  heart,  chiefly  upon  the 
right  auricle." 

I  have  quoted  the  foregoing  minute  autopsy  at  length,  as  it  is  the 
only  one  I  am  acquainted  with  in  which  the  condition  of  the  heart 
and  lungs  had  been  carefully  described.  In  that  case  it  is  quite  man- 
fest  that  the  pulmonary  affection  could  be  traced  to  the  disease  in  the 
ear,  the  phlebitis  set  up  in  the  lateral  sinus  having  extended  to  the 
large  vessels,  and  the  heart  and  limgs.  Dr.  Watson  of  London,  has 
related  some  instances  of  this  nature. 

Sometimes  there  is  an  aperture  in  the  dura  mater  communicating 
at  the  diseased  part  of  the  bone  with  an  abscess  in  the  brain.  The 
last  case  which  I  had  an  opportunity  of  examining,  and  for  which  I 
am  indebted  to  Dr.  Banks,  is  as  follows : — 

"  A  sweep,  aged  21,  was  admitted  into  the  Hardwicke  Hospital  in 
January  last ;  five  days  previously  he  had  a  severe  rigor,  which  was 
succeeded  by  intense  headache,  chiefly  referable  to  the  frontal  and  pa- 
rietal bones,  and  Avas  much  aggravated  when  the  patient  assumed  the 
erect  position ;  there  was  a  purulent  discharge  from  the  right  ear,  but 
which  the  man  said  '  was  of  no  consequence,  as  it  had  existed  since 
he  was  ten  years  old,  without  causing  any  inconvenience  except  deaf- 
ness;' pressure  over  the  parotid  region  caused  pain.  The  patient 
seemed  listless  and  drowsy,  and  required  to  be  questioned  loudly 
before  he  answered  ;  the  pupils  were  dilated ;  the  pulse  only  54,  and 
intermitting.  His  head  was  shaved  and  blistered,  leeches  were  ap- 
plied to  his  temple,  and  he  was  put  upon  the  use  of  mercury.  Ten 
days  subsequently  all  his  symptoms  had  increased,  and  continuous  de- 
lirium ensued,  but  he  was  not  unconscious,  and  could  be  roused  when 
spoken  to.  On  the  thirteenth  day  after  his  admission,  and  the  eigh- 
teenth from  the  date  of  the  rigors,  he  had  low,  muttering  delirium, 
continuous  tossing  of  the  hands  and  rolling  of  the  eyes ;  and  he  died 
without  having  convulsions."  The  following  was  the  post  mortem 
appearance.  "  On  opening  the  skull  lymphy  pus  was  found  effused 
around  the  pons  and  medulla  oblongata.  The  dura  mater  was  sepa- 
rated from  the  petrous  portion  of  the  temporal  bone  by  purulent  mat- 
ter ;  that  membrane  adhered  to  the  brain,  and  when  separated,  an 
opening  was  produced  in  it,  and  also  in  the  cerebral  mass,  which  led 
into  an  abscess,  containing  fetid  green  pus.  The  abscess,  which 
passed  upwards,  opened  into  the  inferior  cornu  of  the  lateral  ventriclej 


408  OTORRHCEA.  —  HEAD    AFFECTIONS. 

■which  was  filled  by  a  sero-purulent  fluid,  and  lined  by  a  vascular  se- 
creting membrane.  The  pus  then  passed  into  the  opposite  ventricle, 
and  down  through  the  third  and  fourth  ventricles,  finally  passing  out 
to  the  surface  of  the  brain  between  the  medulla  and  cerebellum." 

I  made  a  careful  examination  of  the  temporal  bone.  An  abscess, 
apparently  of  long  standing,  and  of  a  narrow  tortuous  course,  sur- 
rounded the  lower  and  anterior  portion  of  the  external  auditory  pro- 
cess, where  the  bone  was  completely  denuded,  but  it  remained  of  its 
natural  color  and  consistence.  It  communicated  with  the  floor  of  the 
external  meatus,  at  a  point  anteiior  to  the  insertion  of  the  membrana 
tympani.  The  membrana  tympani  itself,  and  the  ossicles,  had  been 
completely  removed;  the  cavity  of  the  tympanum  was  filled  with 
dark-colored  fetid  pus,  and  its  lining  membrane  thickened,  pulpy,  and 
of  a  reddish  drab  color.  The  mastoid  cells  presented  a  precisely 
similar  appearance  (see  page  344),  and  in  several  of  them  this  pulpy 
state  of  the  membrane  completely  filled  up  their  cavities,  and  bulged 
above  the  level  of  the  section  made  through  that  part.  Both  aper- 
tures into'  the  labyrinth  were  open,  and  the  structure  of  the  internal 
ear  was  disorganized.  There  was,  however,  no  communication  from 
without  into  the  cavity  of  the  cranium  ;  but  the  surface  of  the  petrous 
bone  corresponding  to  the  site  of  the  aperture  in  the  dura  mater  was 
of  a  dark  and  somewhat  greenish  hue.  On  making  an  oblique  sec- 
tion through  the  bone,  between  this  dark  mark  and  the  cavity  of  the 
tympanum,  traversing  the  j)osterior  margin  of  the  bony  meatus,  the 
same  dark  tinge  was  apparent,  showing  the  track  of  the  morbid  action 
which  passed  from  without  inward ;  but  there  was  no  caries  or  necro- 
sis observable  in  any  portion  of  the  bone  submitted  for  my  inspection. 

Circumscribed  inflammation  and  abscess  of  the  brain,  causing 
absorption  or  caries  of  the  temporal  bone,  may  (it  is  said)  produce 
otorrhoea,  and  the  pus  may  be  discharged  through  the  ear.  Dr.  Cor- 
rigan  related  a  case,  and  exhibited  specimens,  in  1841,  that  would,  at 
first  sight,  appear  to  lend  credence  to  this  opinion.  A  female,  aged 
29,  was  received  into  hospital  semi-comatose,  retching,  with  a  slow 
pulse,  pain  in  the  head,  and  a  copious  fetid  discharge  of  purulent 
matter  from  the  right  ear.  Five  days  after  admission  she  died ;  on 
examination  it  was  found  that  "  the  brain  appeared  dry  superiorly, 
and  the  veins  enormously  distended  with  dark-colored  blood ;  at  the 
base  of  the  brain,  on  the  right  side,  was  an  abscess,  in  the  substance 
of  the  brain  itself,  not  encysted,  and  filled  with  a  green  fetid  pus. 
Sero-purulent  matter  was  effused  at  the  base  of  the  brain.     The  pe- 


OTORKHCEA.  —  HEAD    AFFECTIONS.  409 

trous  portion  of  the  temporal  bone  "was  carried  to  a  considerable 
extent ;  the  dura  mater  covering  it  was  discolored,  and  there  was  puru- 
lent matter  beneath  it."  "It  had  been  a  question,"  he  adds, 
"  whether  the  disease  of  the  brain  or  that  of  the  bone  was  the  earlier. 
In  his  cases  they  appeared  both  to  proceed  j^arz  passic."  We  are 
not  informed,  however,  how  long  the  discharge  from  the  ear  had  ex- 
isted, I  would  say  it,  or  rather  the  disease  of  which  it  was  a  symp- 
tom, had  existed  long  before,  and  had  produced  the  affection  of  the 
bone,  and  subsequently  that  of  the  brain.  Authors  speak  also  of 
abscesses  and  collections  of  matter  within  the  cranium  finding  their 
way  through  the  petrous  portion  of  the  temporal  bone,  into  the  exter- 
nal auditory  tube.  This  is  a  doctrine  I  cannot  subscribe  to — it  is 
unsupported  by  facts ;  it  is  much  more  probable,  that  if  the  brain  was 
the  original  seat  of  disease,  that  death  would  have  ensued  long  before 
this  matter  could  find  an  outlet  through  the  very  hardest  bone  in  the 
whole  body. 

It  is  unnecessary  to  multiply  examples,  proving  the  fatal  results  of 
neglected  otorrhoea.  The  nervous  symptoms  which  sometimes  attend 
those  cases  during  life  are,  as  already  stated,  very  anomalous.  About 
three  years  ago,  I  attended  a  case  in  connexion  with  Dr.  Cuthbert,  of 
which  the  following  are  the  particulars.  Master  J.,  aged  7,  of  a 
strumous  habit  and  delicate  make,  had  long  suffered  from  ophthalmic 
inflammation,  and  it  was  observed  that  whenever  the  ocular  affection 
improved,  he  was  attacked  with  pain  in  his  ear,  which  was  generally 
relieved  by  a  profuse  discharge  (see  page  265).  I  saw  him  in  the  au- 
tumn of  1849 ;  he  then  labored  under  fetid  otorrhoea ;  the  membrana 
tympani  had  been  destroyed,  and  flabby  granulations  sprouted  from 
the  tympanal  cavity.  Towards  the  end  of  December  it  was  observed 
that  the  discharge  from  the  ear  had  considerably  diminished.  The 
boy  appeared  languid,  unusually  quiet,  and  also  a  little  lame.  He 
then  complained  of  a  pain  in  his  left  ankle,  which,  upon  examination, 
was  observed  to  be  red  and  swollen,  presenting  very  much  the  appear- 
ance of  that  form  of  difiiise  inflammation  which  attacks  the  joints 
when  the  system  is  affected  with  any  moAid  poison.  The  pain  in  the 
ankle  became  very  severe,  and  the  slightest  pressm-e  was  intolerable. 
He  was  then  confined  to  bed,  and  lay  chiefly  on  his  back,  moaning 
incessantly  day  and  night.  High  fever  set  in,  characterized  by  ex- 
ceedingly rapid  pulse,  total  sleeplessness,  constant  watching,  a  flushed 
face,  great  heat  of  head,  and  general  excitement.  His  temper  became 
remarkably  irritable;  latterly  he  seldom  spoke,  and  disliked  being 


410  HEARING    TRUMPETS. 

questioned,  but  could  answer  rationally  when  lie  liked.  He  lay  on  his 
back,  and  had  many  symptoms  resembling  catalepsy,  particularly  of 
the  upper  extremities,  which  would  remain  for  hours  in  the  position 
they  were  placed  by  the  attendants.  He  evinced  great  dislike  to 
have  his  head  moved  ;  there  was  no  tenderness  over  the  mastoid  pro- 
cess, or  any  portion  of  the  scalp.  The  meatus  was  still  soiled  with 
brownish  fetid  discharge.  The  condition  of  the  ankle  remained  in 
the  same  state  throughout.  He  had  no  convulsions ;  neither  were 
rigors  observed  in  the  progress  of  the  case,  which  lasted  about'  six 
weeks.  He  died  comatose.  The  friends  did  not  permit  an  examina- 
tion. The  treatment  consisted  in  the  use  of  mercury,  both  internally 
and  by  inunction,  and  the  application  of  blisters  to  the  shaven  scalp. 
The  foregoing  section  having  extended  to  its  present  length,  I  have 
been  obliged  to  omit  the  insertion  of  cases  illustrative  of  ordinary 
otorrhoea  and  polypi,  &c.,  and  must,  therefore,  refer  the  reader  for 
such  to  my  former  essay  upon  this  subject,  and  also  to  papers  pub- 
lished in  the  Medical  Times  and  Gazette  during  the  last  two  years. 
I  have,  in  conclusion,  but  to  entreat  my  professional  brethren  to  exa- 
mine with  greater  care  diseases  of  the  ear ;  to  be  more  guarded  in 
the  opinions  they  give  with  respect  to  aural  discharges ;  and  instead 
of  "  leaving  them  to  nature,"  and  promising  patients  "  that  they  will 
grow  out  of  them,"  to  endeavor  to  heal  them  in  their  early  stage, — 
as  a  class  of  diseases  which,  independent  of  their  unseemliness  and 
injurious  effect  upon  hearing,  may  at  any  time  give  rise  to  symptoms 
which  may  prove  destructive  to  life. 

HEARING   TRUMPETS. 

Various  ingenious  contrivances  have  for  a  long  period  of  time  been 
invented  for  the  purpose  of  assisting  the  partially  deaf;  but  their 
consideration  belongs  more  to  the  instrument-maker  than  the  surgeon. 
They  may  be  divided  into  those  worn  on  the  head ;  those  held  in  the 
hand,  and  applied  to  the  ear  occasionally ;  and  chairs  fitted  with 
acoustic  apparatus  for  the  purpose  of  collecting  and  transmitting,  in 
a  concentrated  form,  surrounding  conversation  to  persons  seated 
therein.  I  have  not  yet  seen  any  contrivance  which  enables  deaf 
persons  to  hear  well  in  a  public  assembly ;  but  it  is  possible  that  such 
yet  may  be  invented.  Generally  speaking,  partially  deaf  patients 
have  a  great  objection  to  the  emj)loyment  of  large  or  visible  me- 
chanical apparatus,  and  certainly,  as  long  as  persons  are  able  to  hear 


HEARING    TEUMPETS.  411 

■\vhat  is  said  to  them  in  a  plain  distinct  voice,  not  pitched  too  high,  I 
do  not  advise  the  use  of  an  ear-trumpet.  The  cases  which  derive 
most  benefit  from  artificial  means  are  those  of  pure  nervous  deafness, 
or  such  as  have  lost  the  membrana  tympani  and  some  of  the  ossicula 
in  early  life.  Patients  with  dense  white  tympanal  membranes  (in 
which  case  I  beheve  the  lining  of  the  tympanic  cavity  is  also  afiected 
by  the  result  of  chronic  inflammation)  do  not  derive  as  much  benefit 
from  mechanical  appliances  as  either  of  the  former. 
,  A  flexible  tube,  provided  at  one  end  with  an  ivory  trumpet-mouth, 
and  at  the  other  with  a  small  ferrule,  which  fits  into  the  meatus, 
answers  well  for  conversing  with  a  person  at  a  little  distance,  and 
may  be  whispered  into ;  but  it  requires  to  have  the  mouth  applied 
very  near  the  trumpet-shaped  extremity,  and  is,  therefore,  not  so 
convenient  as  a  metallic  trumpet  with  a  large  extremity,  which  col- 
lects sound,  and  gathers  the  conversation  of  those  in  the  immediate 
vicinity.  The  best  of  these  latter  is  that  in  which  the  extremity  of 
the  trumpet  is  curved  downwards,  and  opens  into  a  bell-shaped  conch, 
and  which  is  generally  known  by  the  name  of  Miss  Martineau's 
trumpet.  Mr.  Rein,  an  instrument-maker  in  the  Strand,  London,  has 
given  much  attention  to  the  subject,  and  made  many  improvements 
therein. 


APPENDIX. 


DEAF-DUMBNESS. 

Claims  of  the  Deaf  and  Dumb  :  their  Condition  in  Ancient  Times ;  their  Uninstructed 
State. — History  of  their  Education,  and  Literature  relating  to. — Statistics  of:  European 
American,  Irish. — Subdivisions  of  Muteism:  Congenital;  First  Development  of  Speech. 
— Acquired;  Causes  of. — Complications  of  Muteism:  Paralysis;  Idiotcy;  Deformity; 
Blindness. — Dumbness. — Plurality  of  Mutes. — -Sexes. — Marriage. — Family  Position. — 
Twins. — Causes  of  Congenital  Muteism. — Consanguinity  of  Parents. — Hereditary  Taint. 
— Races.-;-Legal  and  Religious  State  of  the  Deaf  and  Dumb. — Feigned  Muteism. — Cures 
of  Muteism. 

As  I  do  not  think  a  work  upon  diseases  of  the  organs  of  hearing  would 
be  complete  without  a  chapter  upon  deaf-dumbness,  I  have  added  the 
following  Appendix.  My  official  position  as  one  of  the  Irish  Census  Com- 
missioners has  not  only  afforded  me  peculiar  means  for  investigating  this 
subject,  but  has  also  directed  my  attention  to  it  in  an  especial  manner;  and 
I  have  reason  to  believe  that  minute  inquiry  into  all  the  circumstances 
relating  to  muteism  which  has  been  lately  carried  on  in  this  portion  of  the 
United  Kingdom,  is  not  only  the  most  correct  which  has  yet  been  undertaken 
in  any  country,  but  is  such  as  to  throw  much  light  upon  the  statistics,  and 
the  social,  moral,  and  physical  condition  of  that  class  of  our  fellow-creatui'es 
deprived  by  congenital  malformation,  accident,  or  disease,  of  the  faculty  of 
hearing,  and,  in  consequence  thereof,  of  the  powers  of  speech.' 

In  any  inquiry  into  the  condition  of  the  deaf  and  dumb,  two  great  objects 

'  These  investigations,  which  are  the  first  of  the  kind  attempted  in  the  British  Isles, 
will  appear  at  length  in  that  portion  of  the  report  of  the  Irish  Census  Commissioners 
on  "  The  Status  of  Disease,"  now  upon  the  eve  of  publication.  A  request,  however, 
having  been  made  by  the  secretaries  to  the  meeting  of  the  British  Association,  at  Bel- 
fast, in  September,  1852,  to  have  the  result  of  the  inquiry  instituted  into  the  number  and 
condition  of  the  deaf  and  dumb  in  Ireland  laid  before  the  Statistical  Section,  I  gave' — 
with  the  permission  of  his  Excellency  the  Earl  of  Eglinton  and  Winton,  then  Lord 
Lieutenant  of  Ireland,  and  with  the  concurrence  of  the  Chief  Commissioner,  Mr.  Don- 
nelly— an  abstract  of  that  portion  of  the  census.  Notices  of  that  communication  have 
appeared  in  the  local  newspapers,  and  a  revised  resume  of  it  was  published  in  the  Jour- 
nal of  the  Statistical  Society  of  London,  for  March,  1853. 


APPENDIX.  413 

present — a  physiological  and  a  social.  Under  the  former  the  deaf  mute 
may  be  classed  among  those  afflicted  with  permanent  disease,  either  con- 
genital or  acquired,  and,  as  such,  demands  the  careful  investigation  of  the 
statistician  j  and  all  the  causes  and  phenomena  of  the  affection  solicit  atten- 
tion equally  with  those  circumstances  attendant  upon  lunacy,  idiotcy,  blind- 
ness, or  any  of  the  other  persistent  maladies  which  affect  certain  portions  of 
the  community  in  all  countries.  Under  the  latter  head  the  deaf  mute 
claims  the  special  attention  of  the  philanthropist,  and  the  protection  of  the 
state,  owing  to  the  forlorn  condition  to  which  he  is  reduced  by  his  affliction, 
the  difficulty  he  experiences  in  expressing  his  wants,  and  his  inability  either 
to  educate  himself,  or  to  receive  instruction  through  the  ordinary  channels; 
and  also  his  constant  exposure  to  crime,  from  the  defect  of  moral  training, 
and  the  difficulty  of  impressing  upon  him  a  just  idea  of  right  and  wrong. 
Degraded  by  his  uncontrolled  passions,  he  is,  moreover,  frequently  the 
victim  of  cruelty  and  injustice;  and  being  incapable,  without  education,  of 
properly  understanding  or  duly  appreciating  the  truths  of  religion,  he  is 
reduced  to  a  condition  but  little  elevated  above  that  of  the  brute  creation. 
Alone  in  the  world,  his  faculties  undeveloped,  and  shut  out  by  his  un- 
happy circumstances  from  thoroughly  communicating  his  ideas  to  the  rest 
of  mankind,  the  deaf  mute,  in  an  especial  manner,  claims  the  sympathies 
of  all. 

Viewed  in  a  statistical  aspect,  the  investigation  of  this  species  of  perma- 
nent disease  leads  us  to  inquire  into  its  extent  and  distribution,  and,  as  far 
as  possible,  its  causes  also ;  the  proportion  of  those  affected  to  the  general 
population,  and  the  relative  proportion  of  the  sexes, — their  education,  and 
susceptibility  to  education,  both  literary  and  industrial, — the  class  of  the 
community  which  the  disease  chiefly  affects, — and  the  localities  where  it 
principally  prevails,  in  order  to  see  whether  geological  position,  soil,  aspect, 
elevation,  humidity,  dryness,  salubrity  or  insalubrity  of  climate,  density  or 
paucity  of  population,  unhealthy  crowded  cities,  or  open  fertile  plains, 
acquired  diseases,  hereditary  predisposition,  family  peculiarity,  or  the  con- 
sanguinity of  parents, — may  in  any  way  conduce  to  its  development  and 
propagation. 

Although  it  appears  from  sacred  history,  that  deaf  mutes  existed  from 
the  earliest  times  (Exodus  iv.  11),  no  effort  was  made  to  afford  them  in- 
struction until  a  comparatively  recent  period.  In  those  ages  wont  to  be 
called  enlightened,  and  among  those  nations  styled  civilized,  and  even  re- 
fined, as  the  Egyptians,  Hebrews,  Greeks,  and  Romans,  the  deaf  mute  was 
— and  even  at  the  present  day,  in  the  Orient,  is — regarded  as  little  re- 
moved from  the  brute,  and  was  often  employed  for  the  basest  and  most 
degrading  offices,  such  as  humanity  revolts  at.  It  was  believed  in  ancient 
times,  and  the  idea  is  still  entertained  in  other  countries  less  favored  than 
our  own,  that  the  deaf  and  dumb  are  incapable  of  improvement  or  instrue- 


414  APPENDIX. 

tion  of  any  kind ;  and  thus  tlieir  very  passions,  unrestrained  by  any  influ- 
ence, human  or  divine,  were  frequently  made  to  minister  to  the  cruelty  or 
the  sensuality  of  those  around  them.  The  sagest  of  the  philosophers,  and 
the  most  imaginative  of  the  poets  of  antiquity,  have  left  on  record  the 
opinions  entertained  in  their  days  respecting  the  psychology  of  the  deaf  and 
dumb,  and  from  these  we  learn  that  they  were  out  of  the  pale  of  either  sym- 
pathy or  alleviation — mutum  ac  turpe  pecus.  By  laws  made  in  different 
countries,  and  extending  so  far  back  as  the  date  of  the  Roman  code,  deaf 
mutes  labored  under  legal  disabilities  with  respect  to  property  and  evidence, 
which  have  only  been  removed  since  their  susceptibility  to  education  has 
been  established.  It  remained  for  Christian  benevolence  to  conceive  the 
noble  idea,  and  modern  ingenuity  and  perseverance  to  carry  out  the  great 
work,  of  developing  the  faculties  of  the  solitary  mute,  and  of  giving  him  a 
knowledge  of  good, — of  rendering  him  independent,  and  eliciting  within 
him  feelings  and  aspirations,  that,  but  for  the  blessings  of  enlightenment, 
would  have  slept  until  awakened  in  another  sphere  of  existence. 

For  wealth,  men  have  risked  their  salvation ;  for  fame,  men  have  perilled 
their  existence ;  for  religion  or  enthusiasm,  men  have  died  at  the  stake ; — 
the  miser  or  the  murderer  saw,  however,  the  golden  glare  of  riches  beyond 
the  gulf  of  crime ;  the  warrior  felt  already  the  laurel  on  his  brow,  and  heard 
the  shout  of  his  welcoming  countrymen  as  he  sought  the  thickest  of  the 
fray;  and  the  martyr  beheld  heaven  opening  to  him  in  the  blue  above  his 
head; — but  to  me  it  has  always  appeared  that  the  patient  instructor  of  the 
deaf  and  dumb  deserved  a  reward  which  nothing  earthly  could  bestow. 
And  the  energy,  perseverance,  and  philanthropy  of  those  good  men  who 
have  from  time  to  time  undertaken  in  different  countries  that  herculean 
task  of  teaching  the  eye  to  hear  and  the  hand  to  speak,  have  only  been 
equalled  by  the  eloquence  of  those  who  have  advocated  the  claims  which 
the  deaf  mute  has  upon  all  to  whom  the  Creator  has  afforded  the  blessings 
of  speech  and  hearing. 

Miraculous  interposition  was  exercised  in  favor  of  the  deaf  and  dumb  at 
the  opening  of  the  Christian  era,  when  upon  the  "Ephphatha"  uttered  by 
the  divine  missionary  the  deaf  heard  and  the  dumb  spake.  It  is  remark- 
able that  the  forms  and  complications  of  muteism  observed  in  the  present 
day  are  precisely  similar  to  those  described  as  existing  in  Judea  nearly 
nineteen  hundred  years  ago, — the  deaf  and  dumb;  the  lunatic  deaf  and, 
dumb,  or  those  possessed  with  a  spirit;  the  blind  and  dumb;  and  the  par- 
tially deaf  and  dumb.  Of  the  latter  form  an  instance  is  related  by  St. 
Mark,  of  one  "  who  was  deaf,  and  had  an  impediment  in  his  speech,"  and 
of  whom  it  is  said  that,  when  the  miracle  of  the  Saviour  was  performed, 
"his  ears  were  opened,  and  the  string  of  his  tongue  was  loosed,  and  he 
spake  plain."  It  remained,  however,  for  the  enlightenment  and  benevo- 
lence of  modern  times  to  achieve  the  task  of  systematically  elevating  this 


DEAF-DUMBNESS.  415 

unliappy  class  to  the  level  of  ordinary  humanity,  by  kindness,  judicious 
training,  and  ingeniously  devised  instruction.  The  Venerable  Bede  mentions 
an  instance  of  a  deaf  mute  being  taught  to  repeat  and  understand  certain 
words  and  sentences,  by  John,  Bishop  of  Hagulstad  (now  Hexham),  in 
Northumberland,  so  early  as  the  seventh  century.  That  case  of  "How 
Bishopp  John  cured  a  dumme  man  by  blessing  him"  was,  at  the  time,  be- 
lieved to  have  been  efifected  by  supernatural  agency;  but  an  examination 
into  its  history,  and  the  gradual  process  by  which  the  instruction  was  con- 
veyed, will  convince  the  reader  that  it  in  nowise  deserves  to  be  ascribed  to 
miraculous  interference. 

Since  the  invention  of  printing,  the  history  of  the  instruction  of  the  deaf 
and  dumb  has,  with  the  exception  of  occasional  notices  in  statistical  writings, 
become  the  history  of  muteism. 

Rodolphus  Agricola,  born  near  Cronengen,  in  1442,  alludes,  in  his  "  In- 
ventione  Dialecticcc,"  to  a  deaf  mute  who  was  able  to  write  in  the  fifteenth 
century ;  but  the  record  of  that  instance  is  not  sufficiently  explicit  to  enable 
us  to  draw  any  deductions  therefrom.  How  long  the  being  deprived  of 
speech — the  great  characteristic  of  man — should  have  remained  in  silence 
and  ignorance,  the  fixed  condition  of  the  unhappy,  isolated  mute,  but  for 
the  fatherly  affection  of  Joachim  Pascha,  the  chaplain  of  Prince  James  II., 
of  Brandenburg,  it  is  difiicult  to  say.  This  good  man,  about  the  year  1560, 
succeeded  in  instructing  his  own  mute  daughter,  by  means  of  a  series  of 
pictures,  mimic  signs,  and  illustrations  of  a  similar  character. 

Jerome  Garden,  of  Pavia,  who  died  at  a  great  age  in  1576,  was  one  of 
the  earliest  to  believe  in  the  possibility  of  instructing  the  deaf  and  dumb, 
and  also  the  blind.  He  was  a  philosopher  of  a  most  extensive  grasp  of  intel- 
lect, as  well  as  a  writer  of  great  brilliancy  and  perspicuity,  and  was  the 
first  to  promulgate  the  doctrine,  that  the  deaf  mute  could  be  taught  to 
"  hear  by  reading,  and  speak  by  writing." 

The  first  systematic  attempt  to  instruct  the  deaf  and  dumb  was  made  by 
Petro  de  Ponce,  a  Benedictine  monk,  at  Sagahun,  about  the  middle  of  the 
sixteenth  century,  during  that  bright  period  when  the  literature  of  Spain 
was  graced  by  Cervantes,  and  its  conquests  extended,  and  its  councils  ruled, 
by  men  of  the  highest  genius.  It  is  related  by  Morales,  the  historian  of 
that  celebrated  ecclesiastic,  that  he  taught  the  two  mute  sons  of  a  Castiliau 
nobleman,  and  a  young  Arragonese,  to  read,  and  also  to  write  with  elegance, 
not  only  the  language  of  their  own  country,  but  likewise  the  Latin  tongue ; 
and  it  is,  moreover,  stated  that  these  persons  could  understand  by  sight  the 
motions  and  expressions  of  the  lips,  and  that  they  also  spoke  as  do  those 
who  have  been  taught  in  a  modern  deaf  and  dumb  institution.  Of  late 
years  much  additional  information  respecting  the  great  Spanish  teacher  has 
come  to  light,  chiefly  through  the  learning  and  research  of  the  Abbe  Carton, 
of  Bruges,  from  whose  Journal  we  learn  that  he  left  some  autobiographical 


416  APPENDIX. 

notices,  from  which  it  would  appear  that  he  educated  many  more  mutes 
than  has  heretofore  been  supposed,  and  wherein  he  states :  "  To  some  I 
have  taught  the  Latin,  to  others  the  Latin  and  G-reek,  and  to  understand 
Italian.  There  was  one  of  them  who  received  the  orders  of  priesthood,  and 
possessed  a  benefice,  and  who  performed  the  duties  of  his  office  in  reciting 
his  breviary." 

We  cannot,  however,  suppose  that  the  foregoing  instances  were  the  only 
examples  of  educated  mutes  prior  to  the  seventeenth  century.  All  intelli- 
gent deaf  and  dumb  persons  are  acquainted  with  the  language  of  pantomime, 
and  have  certain  arbitrary  signs  by  which  they  can  express  their  meaning 
to  those  accustomed  to  them.  The  adult  illiterate  mutes  among  the  Irish 
peasantry — a  people  remarkable  for  action  and  gesticulation — excel  in  mimic 
signs.  And  from  the  days  of  Aristotle,  who  styled  the  ear  ''  the  organ  of 
instruction,"  to  the  time  of  De  Ponce,  history  is  not  altogether  deficient  in 
instances  of  instructed  mutes,  if  not  in  letters,  at  least  in  art.  Pliny  tells 
us  of  Quintus  Pedius,  a  relative  of  Caesar  Augustus,  who,  though  mute 
from  birth,  attained  to  great  proficiency  in  painting ;  and  in  the  middle  of 
the  sixteenth  century  another  deaf  and  dumb  artist,  Juan  Fernandez  Nava- 
retti,  sufnamed  El  Mudo,  on  account  of  his  infirmity,  flourished  in  Spain, 
whose  acquirements  are  thus  summed  up  in  his  epitaph  :  "  Heaven  denied 
him  the  gift  of  speech,  that  he  might  give  greater  life  and  eloquence  to  the 
works  of  his  pencil ;  and,  as  he  could  not  speak  himself,  he  made  them 
speak  for  him." 

De  Ponce  died  in  1584 ;  but  his  system  appears  to  have  been  followed 
up  by  his  countryman,  the  monk,  John  Paul  Bonet,  who  published  at 
Madrid,  in  1620,  a  book,  upon  the  mode  of  teaching  the  deaf  and  dumb, 
'■'■  Keduccion  de  las  Letterasy  Arte  para  encehar  a  hablar  los  Iludos,"  which 
is,  I  believe,  the  earliest  work  extant  upon  the  subject.  How  far  Bonet 
was  acquainted  with  the  labors  of  De  Ponce,  it  is,  at  this  distance  of  time, 
difficult  to  decide ;  but  it  is  remarkable  that  he  does  not  allude  to  him. 
The  Spaniards  were  not,  however,  unmindful  of  De  Ponce's  labors ;  for  in 
the  fourth  volume  of  Friar  Beneto  Peyjoo's  "  Cartas  Eruditas  y  Curiosas,"'- 
printed  in  1733,  there  is  a  chapter  devoted  to  the  subject,  in  which  the  just 
claims  of  De  Ponce  have  been  defended.  From  the  days  of  Bonet  until  the 
commencement  of  the  present  century,  the  condition  of  the  deaf  and  dumb 
does  not  appear  to  have  attracted  attention  in  Spain.  In  the  year  1800,  Dr. 
Joseph  M.  Alea,  a  pupil  of  the  Abbe  de  I'Epee,  opened  a  private  institution 
for  the  instruction  of  mutes  at  Madrid;  in  1805,  a  national  school  for  the 
same  purpose  was  established  there ;  a  similar  institution  has  since  been 
opened  at  Barcelona. 

I  I  am  indebted  to  Dr.  R.  R.  Madden  for  this  rare  work,  as  well  as  for  information 
on  the  present  statistics  of  the  deaf  and  dumb  in  Spain  and  Portugal. 


DEAF-DUMBNESS.  417 

I  am  not  acquainted  with  any  Portuguese  works  upon  the  subject  of  the 
deaf  and  dumb,  and  it  does  not  appear  that  any  interest  was  taken  by  the 
inhabitants  of  that  country  in  the  condition  of  the  deaf  and  dumb,  Until 
two  Swedish  gentlemen,  the  brothers  Borg,  founded  a  school  for  the  educa- 
tion of  the  deaf  and  dumb  at  Belem,  near  Lisbon,  in  1824. 

The  Spanish  system  was  improved  upon  in  Germany,  as  we  learn  from 
the  book  of  J.  R.  Camerarius,  published  at  Strasburg  in  1624  ;  but,  from 
the  writings  of  Caspar  Schott,  it  would  appear  that  the  instruction  of  the 
deaf  and  dumb  had  been  practised  by  Fabricius,  the  celebrated  anatomist  of 
Aquapendente.  About  the  middle  of  the  eighteenth  century  private  teachers 
sprang  up  in  different  parts  of  Europe,  the  most  successful  of  whom  was 
George  Raphel,  a  German,  who,  in  1718,  gave  an  account  of  the  method 
by  which  he  had  instructed  his  own  three  mute  children.  Professor  Jacob 
Wild,  of  Lufland,  was  also  very  successful  in  instructing  the  deaf  and 
dumb.  The  first  public  institution  for  the  education  of  the  deaf  and  dumb 
was  established  at  Leipzig  in  1779,  through  the  instrumentality  of  Samuel 
Heinicke,  the  great  upholder  of  the  vocal  or  articulatory  system  which  is 
still  retained  at  Vienna  and  in  most  of  the  German  schools.  The  most 
learned  German  work  on  the  subject  of  the  deaf  and  dumb  with  which  I 
am  acquainted,  is  that  of  Dr.  Schmalz,  referred  to  at  page  43. 

The  art  made  some  progress  in  Italy 'during  the  middle  of  the  seven- 
teenth century,  as  we  learn  from  the  work  of  Pierre  de  Castro,  a  physician, 
which  gives  an  account  of  a  son  of  Prince  Thomas,  of  Savoy,  who  had  been 
highly  educated  by  E.  R.  de  Carion.  Padre  Lana-Terzi,  of  Brescia,  devoted 
his  time  to  the  instruction  of  both  the  deaf  and  dumb  and  the  blind ;  and 
his  work  on  Natural  History,  published  in  1670,  contains  some  philosophi- 
cal remarks  on  the  mechanism  of  speech  and  the  articulating  system.  In 
1784,  a  philanthropic  citizen,  Don  Pascal  de  Pietro,  founded  a  day  school 
for  deaf  mutes  at  Rome ;  at  the  commencement  of  the  present  century  it 
had  fallen  into  disuse,  but  was  revived  in  1841. 

Even  as  early  as  1657,  the  Dutch  writers  considered  the  question  of 
teaching  the  deaf  and  dumb,  in  discussing  the  subject  of  a  universal  lan- 
guage, which  then  occupied  the  attention  of  the  learned;  and  Baron  P. 
Von  Helmont,  M.D.,  brother  to  the  celebrated  chemist  and  philosopher  of 
that  name,  entered  into  it  fully  in  his  work  on  the  Natural  Alphabet  and 
the  Origin  of  Letters.  Towards  the  close  of  the  seventeenth  century, 
philanthropists  and  men  of  learning  in  Holland,  a  country  then  in  close 
relationship  with  England,  were  not  behindhand  in  attempting  to  educate 
the  deaf  and  dumb.  Amongst  the  foremost  of  these  was  Dr.  John  Conrad 
Amman,  who  instructed  a  mute  girl  at  Haarlem,  and  who,  at  the  time  he 
wrote  his  celebrated  work,  "  Surdus  Loquens,"  in  1690,  was  in  communica- 
tion with  Wallis.     He  afterwards  published  an  enlarged  treatise  on  the 

27 


418  APPENDIX. 

subject,  styled,  '' Dissertatio  de  Loquenda/'  The  former  was  translated 
into  English  by  Foot  in  1694. 

In  France,  during  the  middle  and  latter  part  of  the  eighteenth  century, 
much  attention  was  attracted  by  the  teaching  of  Father  Yanin  and  Madame 
de  Sainte  Rose,  and  in  particular  to  that  of  J.  R.  Pereira,  a  Portuguese 
Jew,  who  is  said  to  have  invented  a  syllabic  manual  alphabet.  Until  lately 
the  merits  of  Pereira — a  teacher  whom  Buffon  styled  "I'homme  miique, 
I'homme  necessaire  de  cet  art  inconnu" — do  not  appear  to  have  been  suflS.- 
ciently  known  or  appreciated.  A  work,  however,  has  lately  been  published 
in  his  defence  by  M.  E.  Seguin,  at  Paris.  About  the  same  time,  the  bene- 
volent Abbe  de  I'Epee,  who  devoted  his  whole  life  and  fortune  to  the  sub- 
ject, brought  the  system  of  instructing  deaf  mutes  to  great  perfection  in 
the  Royal  Parisian  Institution,  then  recently  established.  He  died  in  1789, 
but  his  efforts  were  successfully  carried  out  by  the  Abbe  Sicard.  The 
principal  French  work  on  this  subject  is  "De  I'Education  des  Sourds  Muets 
de  Naissance,"  by  Degerando.  Andral  wrote  the  article  Surdi-Mutite  in 
the  Dictionnaire  de  Medecine,  with  great  care,  and  in  a  philosophic  spirit. 
Morel's  Annals  likewise  contain  much  information. ' 

An  educational  establishment  for  the  deaf  and  dumb  was  opened  at  Co- 
penhagen in  1807  at  the  expense  of  the  state,  and  another  in  Stockholm  in 
1808. 

The  earliest  production  of  an  English  author  in  any  way  relating  to  the 
instruction  of  the  deaf  and  dumb,  is  the  Latin  work  of  Bede,  "  De  Loquela 
per  Gestum  Digitorum,  —  Libellus,''  which  was  printed  at  Ratisbon  in 
1532.  It  contains  plates  illustrative  of  the  manual  alphabet,  and  is,  per- 
haps, the  first  exposition  thereof  extant.^ 

John  Bulwer,  an  English  physician,  who  flourished  about  the  middle  of 
the  seventeenth  century,  is  the  earliest  writer  in  our  language  upon  the  sub- 
ject of  the  deaf  and  dumb.  He  published  two  books,  the  first  in  1644^: 
"Chirologia;  or,  the  Naturall  Language  of  the  Hand,  composed  of  the 
Speaking  Motions  and  Discoursing  Gestures  thereof:  whereunto  is  added, 
Chironomia ;  or,  the  Art  of  Manuall  Rhetoricke :  consisting  of  the  Natu- 
rall Expressions,  digested  by  Art  in  the  Hand,  as  the  chiefest  Instrument 
of  Eloquence,  by  Historical  Manifestos  exemplified."  In  it  he  gives  an- 
account  of  one  Master  Babbington,  in  the  county  of  Essex,  "  an  ingenious 
gentleman,  who,  through  some  sicknesse,  becoming  deaf,  doth,  notwithstand- 
ing, feele  words,  and,  as  if  he  had  an  eye  in  his  finger,  sees  signes  in  the 
dark;  whose  wife  discourseth  very  perfectly  with  him  by  a  strange  way  of 

'  For  an  account  of  all  the  foreign  publications  on  the  subject  of  the  deaf  and  dumb 
and  the  blind,  I  refer  my  readers  to  the  Liste  Litteraire  Philocophe,  by  M.  Guyot,  of  Cro- 
nengen ;  a  work  of  immense  research. 

2  I  am  indebted  to  a  valuable  bibliographical  paper,  by  Samuel  Porter,  published  in 
the  American  Annals  of  the  Deaf  and  Dumb,  for  a  notice  of  this  book. 


DEAP-DUMBNESS.  419 

arthrologic,  or  alphabet  contrived  on  the  joynts  of  his  fingers;  who,  taking 
him  by  the  hand  in  the  night,  can  so  discourse  with  him  very  exactly ;  for 
he  feeling  the  joynts  which  she  toucheth  for  letters,  by  them  collected  into 
words,  very  readily  conceives  what  she  would  suggest  to  him."  The  second 
work,  published  in  1648,  was  entitled,  "  Philocophus  :  or,  the  Deafe  and 
Dumbe  Man's  Friend.  Exhibiting  the  Philosophicall  verity  of  that  subtile 
Art,  which  may  inable  one  with  an  observant  Eie,  to  Heare  what  any  man 
speaks  by  the  moving  of  his  lips.  Upon  the  same  Ground,  with  the  advan- 
tage of  an  Historicall  Exemplification,  apparently  proving,  That  a  Man 
borne  Deafe  and  Dumbe,  may  be  taught  to  Heare  the  sound  of  words  with 
his  Eie,  and  thence  learn  to  speak  with  his  tongue.  By  (I.  B.)  sirnamed 
the  Chirosopher. — Sic  canimus  Sicrdis." 

Sir  Kenelm  Digby,  in  his  "  Treatise  on  the  Nature  of  Bodies,"  1646, 
gives  an  account  of  a  Spanish  mute  nobleman,  a  pupil  of  Bonet,  of  whose 
ability  to  speak  and  read  on  the  lips  he  was  an  actual  witness.  A  still  more 
remarkable  instance  of  understanding  the  motions  of  the  lips  is  related  by 
Bishop  Burnet,  in  his  "Travels  through  France,  Italy,  and  Germany,"  in 
1685,  of  a  deaf  and  dumb  girl  at  Geneva,  who,  he  said,  "  hath  a  sister  with 
whom  she  has  practised  her  language  more  than  with  any  other ;  and  in  the 
night,  by  laying  her  hand  on  her  sister's  mouth,  she  can  perceive  by  tha 
what  she  says,  and  so  can  discourse  with  her  in  the  night."  It  should,  how- 
ever, be  known  that  the  case  was  not  one  of  congenital  but  acquired  deaf- 
ness, and  that,  as  the  Bishop  says,  "  this  child  hath,  by  observing  the  motions 
of  the  mouths  and  lips  of  others,  acquired  so  many  words,  that,  out  of  these, 
she  has  formed  a  sort  of  jargon,  in  which  she  can  hold  conversation  whole 
days  with  those  that  can  speak  her  own  language." 

In  1669,  Dr.  W.  D.  Holder  wrote  "  The  Elements  of  Speech  ;  an  Essay 
of  Inquiry  into  the  Natural  Production  of  Letters ;  with  an  Appendix  con- 
cerning persons  that  are  Deaf  and  Dumb."  George  Dalgarno,  a  Scotchman, 
resident  at  Oxford,  wrote,  in  1661,  "  Ars  Signorum  vulgo  Character  Uni- 
versalis, et  lingua  Philosophia ;"  and  before  his  death,  which  occurred  in 
1687,  he  published  his  "  Diascolocophus,  or  the  Deaf  and  Dumb  Man's 
Tutor,"  a  work  of  great  merit,  but  which,  though  presented  to  the  public 
in  1680,  does  not  appear  to  have  attracted  so  much  attention  as  that  of 
his  contemporary  Wallis.  Neither  does  it  appear  that  he  reduced  his 
system  to  practice  with  such  effect  as  the  latter.  To  Dalgarno  has 
usually  been  ascribed  the  invention  of  the  first  manual,  or  dactylogic 
alphabet.  These  works  exercised  a  considerable  influence  upon  the  conti- 
nent, particularly  in  Germany. 

Dr.  John  Wallis,  Savilian  Professor  of  Mathematics  in  the  University  of 
Oxford,  in  the  latter  half  of  the  seventeenth  century,  is  generally  awarded 
the  merit  of  having  been  the  first  Englishman  who  brought  to  a  successful 
issue  the  instruction  of  the  deaf  and  dumb.     In  1662  he  exhibited  to  the 


420  APPENDIX. 

Royal  Society,  and  also  to  the  king,  the  first  pupil  on  whom  he  had  expe- 
rimented, and  his  essay  upon  the  subject  was  published  in  the  Philosophical 
Transactions  in  1698.  Contemporaneously  with  Wallis,  George  Sibscota 
wrote  his  treatise  called  "  The  Deaf  and  Dumb  Man's  Discourse ;  or,  Con- 
cerning those  who  are  born  Deaf  and  Dumb." — 1670. 

Besides  the  works  quoted  above,  both  Wallis  and  Holder  published  papers 
on  the  same  subject  in  the  Philosophical  Transactions.  The  same  publica- 
tion likewise  contains  papers  by  R.  Waller  and  Mr.  Martin  upon  the  sub- 
ject of  the  deaf  and  dumb  (see  vol.  for  1707) ;  the  paper  of  the  latter 
gives  an  account  of  a  native  of  Stratharig  who  was  deaf  and  dumb  from 
birth  till  his  seventeenth  year,  "  at  which  time  he  was  taken  ill  of  a  violent 
fever;  was  bled,  and  the  fever  abated;  after  about  five  or  six  months,  had 
another  attack,  was  not  bled,  and  the  fever  ran  its  natural  course ;  some 
weeks  after  his  recovery,  he  felt  a  motion  in  his  brain  which  was  very  uneasy 
to  him,  and  afterwards  he  began  to  hear,  and  in  process  of  time  to  under- 
stand speech ;  this  naturally  disposed  him  to  imitate  others  and  attempt 
to  speak ;  he  was  not  understood  for  some  weeks,  but  now  he  is  understood 
tolerably  well." 

I  have  already,  at  page  329,  quoted  the  history  of  a  similar  case  related 
by  De  Foe  of  Dickory  Cronke,  a  deaf  mute  who  received  his  hearing  during 
a  severe  illness.  De  Foe  likewise  wrote  the  life  and  adventures  of  Duncan 
Campbell,  the  celebrated  deaf  and  dumb  fortune-teller,  in  1720.  Sir  Wal- 
ter Scott,  in  his  life  of  De  Foe,  describes  Campbell  as  "  a  fellow  who  pre- 
tended to  be  deaf  and  dumb,  and  to  tell  fortunes,"  and  the  same  opinion 
has  been  lately  reiterated  in  America.  I  see  no  reason,  however,  to  dis- 
credit the  narration  of  the  author,  whose  ingenious  work  is  well  worthy  of 
perusal  by  those  who  would  be  acquainted  with  the  early  history  of  the  in- 
struction of  the  deaf  and  dumb  in  England.  Campbell  was,  it  appears,  edu- 
cated by  an  acquaintance  of  Wallis,  whose  system  was  in  De  Foe's  work  first 
made  known  popularly.  Having  mentioned,  in  confirmation  of  Campbell's 
proficiency  the  names  of  several  educated  mutes  then  in  England,  De  Foe 
writes :  "As  there  are  a  great  many  families  in  England  and  Ireland  that 
have  several,  and  some  even  have  five  or  sis  dumb  persons  belonging  to  them, 
and  as  a  great  many  more  believe  it  impossible  for  persons  born  deaf  and 
dumb  to  write  and  read,  and  have  thence  taken  occasion  to  say  and  assert 
that  Mr.  Campbell  could  certainly  speak,  I  could  never  think  it  a  digression 
in  the  history  of  this  man's  life  to  set  down  the  grammar  by  which  he  him- 
self was  taught,  and  which  he  has  taught  others,  two  of  which  scholars  of 
his  are  boys  in  this  town,  partly  to  confute  the  slander  made  against  him, 
and  partly  for  the  help  of  others  dumb  and  deaf,  whose  parents  may  by  these 
examples  be  encouraged  to  get  them  taught." 

We  now  approach  the  most  remarkable  period  in  the  history  of  the  deaf 
and  dumb  in  the  British  Isles.     Thomas  Braidwood,  the  father  of  the  Bri- 


DEAF-DUMBNESS.  421 

tish  instructors  of  the  deaf  and  dumb,  opened  a  school,  on  the  system  of 
Wallis,  in  Edinburgh,  in  1760.  This  was  the  first  academy  of  the  kind  in 
Europe,  and  from  it  sprung  in  after  times  all  the  other  institutions  of  a  like 
nature  in  Great  Britain.  Braidwood  was  induced  to  undertake  the  educa- 
tion of  the  son  of  an  eminent  merchant  at  Leith,  and  was  so  successful  that 
he  afterwards  instructed  as  many  as  twenty  pupils  at  a  time.  The  number 
of  cases  in  which  public,  and  subsequently  national,  institutions  have  arisen 
from  the  interest  awakened  in  some  philanthropic  mind  by  a  mute  child,  is 
truly  remarkable.  Besides  those  alluded  to  in  the  foregoing,  I  may  men- 
tion, in  addition  to  Braidwood,  the  instance  of  Grallaudet  in  America ;  Town- 
send  in  England  ;  and  Orpen  in  Ireland.  Braidwood  did  not  disclose  his 
method  of  teaching,  nor  leave  any  literary  production  behind  him,  but  his 
academy  is  spoken  of  in  terms  of  high  commendation  by  several  distinguished 
writers  of  that  period, — Pennant,  in  his  Tour  through  Scotland  in  1772 ; 
Lord  Monboddo,  in  his  work  on  the  Origin  of  Language,  1773 ;  and  Dr. 
Johnson,  in  his  Journey  to  the  Western  Islands  of  Scotland,  1772.  When 
the  latter  visited  the  '' College  of  the  Deaf  and  Dumb"  at  Edinburgh,  there 
were  twelve  pupils  in  it ;  and  he  says,  "  it  was  pleasing  to  see  one  of  the  most 
desperate  of  human  calamities  capable  of  so  much  help.  Whatever  en- 
larges hope  will  exalt  courage.  After  seeing  the  deaf  taught  arithmetic, 
who  would  be  afraid  to  cultivate  the  Hebrides  ?"  Herries,  in  his  work  on 
the  Elements  of  Speech,  in  1773,  and  Arnot,  in  his  History  of  Edinburgh, 
likewise  mentioned  Braidwood ;  but  the  work  which  gives  the  fullest  account 
of  his  mode  of  instruction  is,  "Vos  Oeulis  Subjecta  :  a  Dissertation  on  the 
most  curious  and  important  Art  of  imparting  Speech  and  the  Knowledge  of 
Language  to  the  Naturally  Deaf  and  (consequently)  dumb ;  with  a  parti- 
cular Account  of  the  Academy  of  Messrs.  Braidwood,  of  Edinburgh,  and  a 
proposal  to  perpetuate  and  extend  the  benefits  thereof;" — published  in  Lon- 
don, in  1788,  by  an  American  gentleman,  whose  son  Braidwood  had  educated. 
From  it  we  learn  that  articulation  was  one  of  the  chief  means  employed  at  the 
Scottish  Academy,  and  it  would  appear  that  great  perfection  was  attained  in 
speaking  by  the  pupils  educated  there.  To  assist  in  imparting  a  knowledge 
of  vocalization,  we  are  told  that  the  master  employed  a  little  instrument 
composed  of  "  a  small  round  piece  of  silver  of  a  few  inches  long,  the  size 
of  a  tobacco  pipe,  flattened  at  one  end,  with  a  ball  as  large  as  a  marble  at 
the  other,"  for  placing  the  tongue  of  the  pupil  in  the  right  position.  In 
1783,  Braidwood  removed  his  academy  to  Hackney,  near  London,  where  it 
is  said  that  one  of  his  first  pupils  was  a  son  of  the  celebrated  Charles  James 
Fox.  He  died  in  1806,  but  his  institution  was  continued- by  his  widow 
and  grandchildren  until  1816. 

Henry  Baker,  of  London,  who  died  in  1774,  and  who  corrected  stammer- 
ing, and  taught  several  deaf  mutes  to  speak  and  read  on  the  lips,  is  also 
mentioned  by  Dr.  Johnson.     The  Rev.  W.   Dutens,  in  an  article  in  the 


422  APPENDIX. 

Christain  Observer  for  July,  1809,  ^'  On  the  Capacity  of  the  Deaf  and 
Dumb,"  likewise  alludes  to  him  as  a  most  successful  teacher. 

In  1770,  a  translation  of  the  work  of  Professor  Buchner,  of  Halle,  "  An 
easy  and  very  practicable  method  to  enable  Deaf  persons  to  Hear,"  appeared 
in  London.  One  of  the  few  novelties  in  the  book  is  the  account  of  a  parti- 
ally deaf  person,  who  was  enabled  to  hear  by  having  a  thin  slip  of  wood 
touching  his  own  upper  teeth  and  also  those  of  the  person  speaking.  It  is 
needless  to  say,  that  this  device  is  quite  inapplicable  to  the  congenitally  or 
the  totally  deaf  mute. 

Dr.  Joseph  Watson,  a  nephew  of  Braidwood,  published,  in  1809,  a  work 
upon  the  "■  Instruction  of  the  Deaf  and  Dumb ;  or  a  Theoretical  and  Prac- 
tical Means  by  which  they  are  taught  to  speak  and  understand  a  language," 
&c.  The  first  public  school  for  the  gratuitous  instruction  of  the  deaf  and 
dumb  in  Great  Britain  was  established  at  Bermondsey,  near  London,  in 
1792,  chiefly  through  the  instrumentality  of  the  Rev.  John  Townsend,  who 
so  largely  contributed  to  the  formation  of  the  London  Missionary  and  the 
British  and  Foreign  Bible  Societies.  From  it  sprung  the  London  Asylum 
in  Kent-road,  opened  in  1807,  by  Mr.  Townsend  and  the  Rev.  H.  C.  Mason; 
Dr.  Watson  was  first  master  of  it.  A  volume  of  memoirs  of  Mr.  Townsend 
has  been  already  published  both  in  England  and  America. 

In  1801,  a  translation  of  the  Abbe  de  I'Epee's  "  Method  of  Educating 
the  Deaf  and  Dumb,  confirmed  by  long  experience,"  was  published  in  Lon- 
don, in  which  the  system  of  that  celebrated  teacher  was  fully  expounded. 
A  deaf  and  dumb  boy,  who  was  found  wandering  through  the  streets  of 
Paris,  was  adopted  and  educated  by  the  good  Abbe,  and  named  Theodore. 
"This  boy  was  afterwards  discovered  to  be  the  son  of  a  nobleman,  and  the 
rightful  heir  of  a  large  fortune,  of  which  he  had  been  deprived  by  the  vil- 
lany  of  a  near  relative."  So  romantic  an  incident  naturally  attracted  much 
attention  in  Paris,  and  became  the  basis  of  a  drama,  by  M.  Bouilly,  entitled, 
"  L'Abbe  de  I'Epee,"  which  was  long  popular  in  the  French  capital,  and 
has  been  translated  into  English  and  several  other  languages.  De  I'Epee 
was  the  great  advocate  in  his  day  for  methodical  signs;  and  both  in  his 
time  and  since,  several  attempts  have  been  made  to  compile  a  system  of 
such,  of  which  the  latest  is  that  recently  made  in  this  city  by  the  publica- 
tion of  a  prospectus,  from  a  number  of  benevolent  individuals,  in  which 
premiums  are  off"ered  by  a  mute  gentleman  for  the  best  essays  on  a  Diction- 
ary of  Universal  Signs. 

The  various  works  upon  the  structure,  physiology,  or  the  diseases  of  the 
ear,  already  referred  to  in  the  bibliographical  sketch  at  the  commencement 
of  this  work,  allude  either  directly  or  incidentally  to  the  subject  of  deaf- 
dumbness;  but,  upon  the  whole,  practitioners  in  aural  surgery  are  gene- 
rally not  so  well  informed  upon  the  subject  as  instructors  of  the  deaf  and 
dumb. 


DEAF-DUMBNESS.  423 

The  different  eyclopsedias  published  in  Grreat  Britain  during  the  early 
portion  of  the  present  century  contain  articles  upon  the  ear,  deafness,  and 
the  deaf  and  dumb;  but,  although  very  correct  as  regards  anatomy  and 
physiology,  they  are  defective  in  the  statistics  relating  to  that  class,  and 
also  as  to  the  mode  of  their  instruction,  &c.  The  article  in  Rees's  Cyclo- 
paedia is  especially  of  this  class.  Dr.  Gordon  wrote  the  article  "  Dumb 
and  Deaf,"  in  the  Edinburgh  Encyclopaedia,  with  great  care  and  attention, 
and  Dr.  Roget,  already  so  well  known  to  science,  supplied  that  upon  the 
"Deaf  and  Dumb"  to  the  Encyclopaedia  Britannica;  but  by  far  the  best 
modern  article  which  has  appeared  in  publications  of  this  nature,  is  that  in 
the  Penny  Cyclopedia,  published  in  1837,  and  which  was  contributed  by 
Mr.  Charles  Baker,  Head  Master  of  the  Yorkshire  Institution.  To  this 
gentleman  science  and  humanity  are  likewise  indebted  for  several  articles  re- 
lating to  the  deaf  and  dumb,  published  in  the  works  of  the  Society  for  the 
Diffusion  of  Useful  Knowledge,  and  also  for  many  valuable  educational 
books. 

In  1819,  J.  P.  Arrowsmith  published  in  London  "  The  Art  of  Instruct- 
ing the  Infant  Deaf  and  Dumb;"  the  object  of  which  was  to  show  that 
they  could  be  educated  with  equal  facility  at  home,  or  in  schools  for  hear- 
ing and  speaking  children,  as  in  institutions  specially  intended  for  the  deaf 
and  dumb.  Mr.  Arrowsmith  was  not  himself  a  professional  instructor  of 
the  deaf  and  dumb,  but  having  a  mute  brother,  his  attention  was  in  a 
special  manner  .directed  to  the  subject.  In  that  work  the  author  criticises 
the  management  of  the  British  Institutions,  for  having  devoted  too  much 
time  and  attention  to  the  subject  of  utterance;  and  the  British  teachers,  for 
having  made  so  much  mystery  of  their  art,  and  keeping  a  knowledge  of  it 
concealed  unless  when  paid  a  large  sum  of  money.  In  this  latter  particu- 
lar the  author  was  fully  justified;  his  work  would,  however,  have  attracted 
but  little  attention  had  it  not  been  noticed  in  the  London  Quarterly  Review 
for  1822.  A  similar  proposition  to  Arrowsmith's — of  educating  deaf 
mutes  along  with  hearing  children — was  some  time  afterwards  made  in  Bel- 
fast, and  some  experiments  tried,  but  the  scheme  proved  unsuccessful. 

The  claims  of  the  deaf  and  dumb  are  now  fully  acknowledged  by  the 
British  public ;  and  although  the  Legislature  has  not  yet  (with  the  excep- 
tion of  a  clause  in  the  Irish  Poor-rLaw  Act)  made  a  state  provision  for  that 
most  helpless  portion  of  the  community,  still  their  cause  was  not  pleaded 
in  vain ;  and  when  their  susceptibility  for  instruction  was  fairly  demon- 
strated, sympathy  and  support  followed. 

We  now  approacb  a  period  when,  with  the  advance  of  civilization,  the 
public  mind,  having  been  awakened  to  the  possibility  of  educating  the  deaf 
and  dumb,  became  impressed  with  the  necessity  of  affording  them  special 
instruction.  This  persuasion  actuating  the  governments  of  most  countries 
upon  the  continent,  a  state  relief  was  provided  for  the  instruction  of  the 


424  APPENDIX. 

indigent  deaf  and  dumb.  In  the  British  Isles — the  country  of  voluntary 
charity — the  benevolence  of  private  individuals  affected  a  like  object, 
though  not,  perhaps,  to  a  similar  extent.  Besides  that  in  Loudon,  institu- 
tions for  the  gratuitous  education  of  the  deaf  and  dumb  sprang  up  in  other 
parts  of  England,  in  Ireland,  and  also  in  Scotland,  of  which  the  first  was 
that  established  in  Edinburgh  in  1810 ;  since  when,  the  reports  of  the  diffe- 
rent asylums  embody  the  great  bulk  of  the  English  literature  relating  to 
muteism.  The  Edinburgh  Institution  was  for  a  number  of  years  ably  con- 
ducted by  Mr.  Kiuniburgh,  who  had  been  a  pupil  of  the  Braidwoods.  He 
is  the  author  of  several  school-books  for  the  deaf  and  dumb,  chiefly  of  a 
religious  character,  among  which  I  may  specify,  "  A  Catechism  and  Diction- 
ary of  the  First  Principles  of  Religion,  designed  for  the  use  of  the  Deaf 
and  Dumb,"  1831.^  It  is  much  to  be  admired  that  most  of  the  works 
written  by  teachers  of  the  deaf  and  dumb  are  of  a  serious  nature,  and  it 
shows  the  necessity  which  exists  of  combining  religious  with  secular  instruc- 
tion.^ The  governors  of  Donaldson's  Hospital,  one  of  the  noblest  institu- 
tions in  Scotland,  have  lately  opened  a  portion  of  it  for  the  instruction  and 
maintenance  of  the  deaf  and  dumb.  There  are  altogether  four  institutions 
of  this  class  in  Scotland.  A  small  periodical,  styled  "A  Voice  for  the 
Dumb,"  was  published  in  that  country  some  years  ago,  but  I  cannot  state 
with  what  success. 

In  1812  Dr.  De  Lys  excited  considerable  interest  in  Birmingham  by  a 
series  of  public  lectures  upon  the  instruction  of  the  deaf  and  dumb,  illus- 
trated by  an  educated  mute  child;  which  appeal  subsequently  led  to  the 
establishment  of  the  Institution  at  Edgbaston,  near  that  town.  Its  first 
teacher  was  Thomas  Braidwood,  one  of  the  family  of  the  celebrated  Edin- 
burgh Instructor.  The  Committee  of  the  Edgbaston  Institution  devoted 
much  attention  to  reforming  the  system  of  instruction,  believing  that  it  was 
at  first  better  to  improve  the  natural  language  of  gesture  and  expression 
common  to  all  sane  mutes,  "  before  their  memories  are  burdened  with  the 
artificial  expressions  of  thought."  To  this  opinion  they  appear  to  have 
been  urged  by  the  Eev.  W.  C.  Woodbridge,  an  American  instructor,  who 
happened  to  be  then  (1826)  in  England;  and  these  views  were  soon  re- 
duced to  practice  by  M.  Du  Puget,  a  pupil  of  Pestalozzi's,  and  previously 
educated  -at  the  Claremont  Institution  of  Dublin.  Subsequently,  similar 
institutions  sprung  up  in  Manchester,  Liverpool,  Exeter,  Doncaster,  and  in 
other  parts  of  England,  in  all  amounting  at  present  to  eleven,  two  of  which 
are  private,  and  the  rest  are  supported  by  voluntary  contributions. 

To  Dr.  C.  H.  Orpen,  at  present  a  missionary  in  Southern  Africa,  is  due 
the  credit  of  first  drawing  public  attention  to  the  education  of  the  deaf  and 

'  The  London  Catalogue  and  other  Enghsh  bibliographical  lists  are  very  defective  in 
the  enumeration  of  works  relating  to  the  deaf  and  dumb. 

2  We  are  sorry  to  learn  that  Mr.  Kinniburgh  has  emigrated  to  Australia. 


DEAF-DUMBNESS.  425 

dumb  in  Ireland.  He  had  been  attracted  by  the  mode  in  which  Dr.  De 
Lys  had  succeeded  in  awakening  an  interest  in  Birmingham  ;  and  in  1816 
he  took  into  his  house,  and  succeeded  in  instructing,  Thomas  Collins,  a  mute 
orphan  boy,  from  the  House  of  Industry.  By  a  series  of  public  lectures, 
delivered  in  Dublin,  he  enlisted  the  charitable  sympathies  of  the  benevolent, 
and  eventually  succeeded  in  establishing  the  National  Association,  together 
with  the  Institution  at  Claremont,  which  has  since  that  time  been  the  great 
means  of  instructing  the  deaf  and  dumb  in  this  country.  In  these  endea- 
vors he  was  ably  assisted  by  Mr.  Joseph  Humphries,  the  first  Master  of  the 
Institution,  who  had  been  instructed  by  Mr.  Kinniburgh.  A  formidable 
obstacle  to  the  education  of  the  deaf  and  dumb  presented  at  the  commence- 
ment of  the  present  century,  in  the  difficulty  of  procuring  teachers,  and  in 
the  fact  that  those  who  were  in  possession  of  the  requisite  knowledge  made 
it  an  arcana,  and  demanded  a  large  sum  of  money,  as  well  as  vows  of  secrecy, 
from  those  to  whom  they  imparted  it. 

Dr.  Orpen  was  for  many  years  the  Honorary  Secretary  to  the  Deaf  and 
Dumb  Association  alluded  to ;  and  in  1828  he  published  the  first  edition  of 
a  work,  entitled  "  The  Contrast  between  Atheism,  Paganism,  and  Christi- 
anity illustrated ;  or,  the  Uneducated  Deaf  and  Dumb  as  Heathens,  com- 
pared with  those  who  have  been  instructed  in  language  and  revelation,  and 
taught  by  the  Holy  Spirit  as  Christians."  It  was  dedicated  to  the  Bight 
Hon.  Henry  G-oiilburn,  at  that  time  Chief  Secretary  for  Ireland,  through 
whose  influence  the  government  afi"orded  the  Institution  for  the  Deaf  and 
Dumb  such  pecuniary  assistance  as  saved  it  from  ejectment  and  ruin.  The 
book  was  printed  by  Thomas  Collins,  the  deaf  and  dumb  boy,  who  was  Dr. 
Orpen's  first  pupil.  In  1836  a  new  edition,  under  the  title  of  "  Anecdotes 
and  Annals  of  the  Deaf  and  Dumb,"  was  produced  at  the  expense  of  John 
Mortlock,  Esq.,  of  London.  Both  editions  were  largely  distributed  gratui- 
tously. This  book,  which  is  intimately  associated  with  the  first  instruction 
of  deaf  mutes  in  Ireland,  is  well  known  both  in  Europe  and  America.  Dr. 
Orpen  also  wrote  "  Visits  to  Claremont ;  or.  Conversations  and  Correspon- 
dence with  the  Deaf  and  Dumb." — 1829. 

Beports  of  "  The  National  Association  for  the  Education  of  the  Deaf  and 
Dumb  Children  of  the  Poor  in  Ireland,  established  in  Dublin,  18th  May, 
1816,  and  now  situated  at  Claremont,  near  Glasnevin,"  have  appeared 
annually  since  that  period.  The  early  ones  afforded  much  valuable  infor- 
mation upon  the  instruction  of  the  deaf  and  dumb ;  contained  several  in- 
teresting letters  and  communications  from  distinguished  teachers  and  edu- 
cated mutes,  and  were  altogether  well  calculated  to  keep  alive  the  interest 
already  awakened  by  the  energy  and  philanthropy  of  the  Secretary ;  but  of 
late  years  not  more  than  three  or  four  pages  of  these  books  are  devoted  to 
the  subject  of  the  report,  and  even  they  contain  nothing  of  value  as  regards 
the  condition  or  prospects  of  the  deaf  and  dumb,  while  the  remaining  pages. 


426  APPENDIX. 

amounting  to  more  than  one  hundred,  are  occupied  with  lists  of  the  names 
of  subscribers,  &c.  The  reports  of  the  American  Institutions  form  a  striking 
contrast  to  these  latter. 

The  next  attempt  made  to  provide  instruction  for  the  deaf  and  dumb  in 
Ireland  was  that  by  Dr.  Kehoe  of  Cork,  who,  in  1822,  established  a  day 
school  for  mutes  in  that  city ;  it  was,  however,  closed  in  April,  1846,  from 
want  of  support. 

In  1826,  the  family  of  Archbishop  Magee  established  a  day  school  for 
the  instruction  of  the  deaf  and  dumb  in  connexion  with  the  Dorset  Institu- 
tion in  Dublin ,  it  is  used  chiefly  as  a  preparatory  school  for  those  waiting 
to  be  received  into  Claremont. 

In  1831,  some  benevolent  individuals  in  Belfast  founded  ''The  Ulster 
Institution  for  the  Education  of  the  Deaf  and  Dumb,  and  also  of  the  Blind," 
of  that  province ;  and  in  1845,  the  present  noble  building  was  erected  by 
voluntary  contributions,  amounting  to  £10,000. 

An  attempt  was  made  in  1834,  by  Mr.  W.  Craig,  assisted  by  the 
Mercers'  Company  of  London,  to  establish  an  institution  for  the  deaf  and 
dumb  at  Kilrea,  near  Coleraine  ;  it  did  not  exist  much  longer  than  a  twelve- 
month.    ° 

In  1842,  Miss  Wright,  a  benevolent  lady,  established,  and  has  in  great 
part  supported  at  her  own  expense,  an  institution  for  the  education  of  poor 
mute  children  in  Moneymore,  in  the  north  of  Ireland.  The  pupils  are 
taught  wood-carving,  crotchet-work,  and  other  industrial  arts,  thereby  setting 
an  example  worthy  of  imitation  to  most  other  institutions  of  this  class. 

In  1846,  the  clergy  of  the  diocese  of  Derry  and  Baphoe  subscribed  a  sum 
of  money,  with  which  and  some  means  previously  collected  by  a  lady  in  the 
vicinity,  the  Strabane  institution  was  established  both  as  a  day  and  boarding 
school. 

In  the  same  year,  the  late  William  Nugent  Skelly,  the  Very  Eev.  Dr. 
Yore,  and  the  Rev.  Mr.  M'Namara,  commenced  the  "  Catholic  Institutions" 
of  St.  Mary,  at  Cabra,  and  St.  Joseph,  at  Prospect,  in  the  vicinity  of  Dublin. 
The  former  was  opened  for  the  admission  of  female  pupils  in  1847,  and  the 
latter  for  males,  in  1849.  Preparatory  to  the  reception  of  pupils  into  St. 
Mary's  institution,  which  is  under  the  direction  of  the  sisters  of  the  reli- 
gious order  of  St.  Dominick,  two  of  the  ladies  belonging  to  that  establish- 
ment, together  with  two  mute  female  children,  were  sent  to  the  Institution 
for  Deaf  Mutes  of  Le  Bon  Sauveur,  at  Caen,  in  Normandy,  in  order  to  learn 
the  mode  of  instruction  taught  at  that  celebrated  establishment.  The  single- 
handed  alphabet,  similar  to  that  generally  used  on  the  Continent  and  in 
America,  is  the  one  tauglit  in  both  these  institutions.  In  most  of  the  other 
schools  in  Ireland  the  double-handed  alphabet  is  employed.  The  Irish 
schools  in  general  do  not  attempt  to  teach  the  pupils  to  articulate. 

The  circumstances  appertaining  to  the  six  establishments  for  the  instruc- 


DEAF-DUMBNESS.  427 

tion  of  the  deaf  and  dumb,  which  at  present  exist  in  Ireland,  will  be  found 
in  the  details  of  the  Census  Report,  alluded  to  at  page  430.  A  certain 
number  of  the  deaf  and  dumb  in  the  Irish  workhouses  constitute  the  only 
portion  of  the  community  of  mutes  for  whose  education  a  state  provision  has 
been  made.  According  to  the  Poor  Law  Act,  6  &  7  Vict.,  cap.  92,  s.  14, 
it  is  enacted — "  That  the  guardians  of  any  union  may  send  any  destitute 
person,  deaf  and  dumb  or  blind  child,  under  the  age  of  eighteen,  to  any 
institution  for  the  maintenance  of  the  deaf  and  dumb  or  blind,  which  may 
be  approved  of  by  the  Commissioners,  with  the  consent  of  the  parents 
or  guardians  of  such  child,  and  may  pay  the  expense  of  its  maintenance 
there  out  of  the  rates  raised  under  the  authority  of  the  said  first-recited 
Act."  As  mute  children,  permitted  to  grow  up  in  ignorance  and  poverty, 
must  remain  a  permanent  tax  upon  their  respective  unions,  and  as  they  can- 
not be  properly  instructed  except  in  schools  specially  constituted  for  the 
purpose,  it  might  be  found  an  eventual  economy  to  the  unions  to  have 
them  sent  to  some  of  the  existing  seminaries,  that  they  may  receive  both  a 
literary  and  industrial  education.  The  requisites  for  admission  into  all  our 
institutions  are  muteism,  the  pupil  being  of  a  particular  age,  not  being 
defective  in  intellect,  and,  in  most  instances,  having  had  certain  infantile 
diseases. 

A  few  tracts  and  minor  works  calculated  to  interest  young  persons  in  the 
cause  of  the  deaf  and  dumb  have  been  lately  published  in  Ireland. 

Not  many  works  have  appeared  in  England  upon  the  subject  of  deaf- 
dumbness  during  the  present  century.  By  far  the  best  is  that  by  Dr.  Scott, 
principal  of  the  West  of  England  Institution  at  Exeter :  "  The  Deaf  and 
Dumb ;  their  position  in  society,  and  the  principles  of  their  education,  con- 
sidered;" London,  1844; — a  work  which  should  be  in  the  hands  of  every 
parent  or  guardian  of  a  mute  child,  as  it  affords  most  valuable  information 
with  respect  to  the  moral  training  of  the  deaf  and  dumb,  as  well  as  that 
portion  of  instruction  of  which  they  are  susceptible  prior  to  the  age  at  which 
they  are  admissible  into  special  institutions  for  their  education. 

Besides  these  works  already  alluded  to,  several  school-books  adapted  to 
the  deaf  and  dumb  have  been  published  by  Messrs.  Watson,  Vaughan,  and 
others,  while  Mrs.  Sherwood  and  Mrs.  Phelan  (Charlotte  Elizabeth),  the 
former  in  the  tale  of  "Theophilus,"  the  latter  in  that  of  "The  Happy 
Mute,"  made  powerful  appeals  to  public  sympathy  on  behalf  of  the  afflicted 
class  whose  claims  they  advocated.  In  a  work  published  in  London  in 
1827,  "Sketches  of  Imposture,  Deception,  and  Credulity,"  the  subject  of 
feigned  muteism  is  exposed  with  considerable  ability.  In  1833,  Mr.  W.  C. 
Fenton  published  in  London,  "A  Brief  View  of  the  Institutions  for  the 
Deaf  and  Dumb  in  Europe  and  America,  with  some  Remarks  on  the  York- 
shire Institution."  The  Rev.  T.  F.  Dibdin,  in  his  "Tour  in  the  Northern 
Counties  of  England  and  Scotland,"  in  1838,  gives  an  interesting  account 


428  APPENDIX. 

and  also  several  specimens  of  the  etchings  of  Walter  Geikie,  a  deaf  and 
dumb  artist,  which  affords  a  fair  criterion  of  what  may  be  achieved  in  the 
arts  by  educated  mutes.  Of  Dr.  Kitto's  "Lost  Senses,"  and  also  the  works 
of  W.  Thornton,  Mr.  Curtis,  and  other  medical  writers,  I  have  already  given 
an  account  in  the  introductory  chapter  to  this  work. 

Several  of  the  most  devoted  teachers  of  the  deaf  and  dumb  in  the  United 
Kingdom  have  long  desired  to  hold  a  conference  for  their  mutual  improve- 
ment, and  the  advancement  of  that  branch  of  science'  to  which  they  have 
specially  devoted  themselves,  but  until  lately  they  were  not  able  to  accom- 
plish their  wishes.  The  occasion  of  the  Grreat  English  Exhibition  of  1851 
seemed,  however,  to  afford  a  favorable  opportunity  for  bringing  together 
those  gentlemen  interested  in  the  undertaking ;  accordingly,  a  meeting  took 
place  in  London  in  July,  1851,  of  several  of  the  head  masters  of  the  schools 
of  Great  Britain  and  Ireland,  and  was  also  attended  by  some  of  those  of 
America.  The  meeting  was  held  in  the  "Institution  for  providing  Employ- 
ment and  Religious  Instruction  for  the  Adult  Deaf  and  Dumb,"  which  was 
established  in  1841,  and  is  intended  as  well  for  those  who  have  been  educated 
as  those  who,  having  been  left  uneducated,  have  attained  to  such  an  advanced 
age  as  to  'be  inadmissible  into  any  of  the  existing  educational  establish- 
ments. A  second  meeting,  convened  by  Mr.  Baker,  was  held  at  the  York- 
shire Institution  at  Doncaster,  in  July,  1852. 

The  result  of  these  most  useful  reunions  has  been  the  publication  of  the 
"Transactions  of  the  First  and  Second  Conferences  of  Principals  of  Institu- 
tions for  the  Deaf  and  Dumb,"  which  was  printed  by  the  mutes  at  the 
Doncaster  School.  It  is  ardently  to  be  desired  that  these  conferences  should 
continue,  and  that  the  publication  just  alluded  to  should  be  sustained.  It 
might  easily  embody  abstracts  of  the  reports  of  the  different  institutions  in 
the  British  Isles;  notices  of  whatever  useful  discoveries  are  made  in  the 
methods  of  educating  the  deaf  and  dumb ;  and,  in  fact,  be  made  a  magazine, 
similar  to  the  American  Annals,  to  which  I  have  referred  at  page  430, — 
not  only  useful  to  all  those  immediately  concerned  in  the  alleviation  of 
muteism,  but  a  most  effective  means  of  keeping  alive  public  interest  on 
behalf  of  the  deaf  and  dumb. 

We  now  turn  to  America,  where  the  claims  of  the  deaf  and  dumb  have 
not  only  met  with  a  hearty  response  from  the  public,  but  where  the  country 
at  large  has  made  ample  provision  for  their  maintenance  and  instruction. 
So  early  as  1793  there  appeared  in  the  Transactions  of  the  American  Philo- 
sophical Society,  "  Cadmus,  or,  a  Treatise  on  the  Elements  of  Written 
Language,  and  with  an  Essay  on  the  Mode  of  Teaching  the  Deaf  or  Surd, 
and,  consequently.  Dumb  to  speak."  As  I  have  already  mentioned,  the  . 
number  of  instances  in  which  national  institutions  have  had  their  origin  in 
the  interest  awakened  in  some  philanthropic  individual  by  a  mute  child,  is 
remarkable.     In  1807,  the  deaf  and  dumb  daughter  of  Dr.  Cogswell,  of 


DEAF-DUMBNESS.  429 

Hartford,  U.  S.,  attracted  the  attention  and  enlisted  the  sympathies  of  the 
late  Kev.  Thomas  H.  G-allaudet, — a  man  who  united  the  true  principles  of 
charity  with  distinguished  scholarship  and  unwearied  assiduity  and  patience. 
He  subsequently  proceeded  to  Europe,  in  order  to  acquire  the  art  of  im- 
parting instruction  to  the  deaf  and  dumb ;  and  having  remained  for  some 
time  a  pupil  under  the  Abbe  Sicard,  he  returned  to  America,  accompanied 
by  M.  Clerc,  who  was  then  (in  connexion  with  Massieu,  the  favorite  pupil 
of  De  I'Epee)  one  of  the  mute  assistants  of  the  Parisian  Institution. 

The  first  institution  for  the  instruction  of  deaf  mutes  in  America  was 
opened  at  Hartford  in  1817.  Since  then,  no  less  than  twelve  other  large 
establishments  for  a  similar  purpose  have  been  erected  in  that  country ;  and 
the  expenses  in  these  are  defrayed,  like  most  of  those  on  the  Continent  of 
Europe,  by  a  state  provision,  either  in  grants  of  land  or  money. 

The  subject  of  muteism  generally,  as  well  as  the  system  of  instruction  in 
America,  has  engaged  the  attention  of  the  learned  and  benevolent,  and  the 
publications  relating  to  muteism  which  issue  from  the  press  in  that  country 
are  numerous  and  valuable.  The  Reports  which  emanate  from  the  American 
Institutions,  particularly  that  at  New  York,  are  models  of  their  kind.  The 
Rev.  W.  Gallaudet  published  some  sermons  on  muteism,  a  "  Child's  Pic- 
ture, Defining,  and  Reading  Book"  (Hartford,  1830),  and  also  some  re- 
views and  literary  articles  relating  to  the  deaf  and  dumb.  Several  interest- 
ing addresses  on  that  subject  have  been  also  delivered  on  special  occasions 
by  Laurent  Clerc,  Dr.  Mitchell,  Mr.  Lewis  Weld,  and  Mr.  Harvey  Peet. 
These  were  subsequently  published,  and  contain  most  valuable  information. 
Mr.  Peet  has  also  written  several  school-books  and  elementary  works  for 
the  deaf  and  dumb ;  and  to  the  courtesy  of  that  gentleman  I  am  largely 
indebted  for  much  information  regarding  the  American  institutions,  and 
for  an  extensive  collection  of  American  works  relating  to  muteism.  The 
North  American  Review  for  1834  has  a  philosophical  and  admirably  written 
article  upon  the  education  of  the  deaf  and  dumb,  and  the  Philadelphia  edi- 
tion of  the  Encyclopssdia  Americana  likewise  contains  an  article  on  the 
dumb  and  deaf.  The  Christian  Spectator  for  1837,  the  New  York  Literary 
and  Theological  Review  for  1835,  and  the  Biblical  Repository  for  184-2, 
also  contain  articles  on  the  existing  state  of  the  art  of  instructing  the  deaf 
and  dumb.  Tales  and  poems  bearing  upon  the  subject  of  muteism  have 
likewise  appeared  from  the  pens  of  Mr.  Nack,  Mr.  Burnett,  and  Mr.  John 
Edwin  Mann, — the  latter  a  deaf  mute,  educated  at  the  Hartford  Asylum. 

In  October,  1847,  appeared  the  first  number  of  the  American  Annals  of 
the  Deaf  and  Dumb,  originally  conducted  by  the  instructors  of  the  American 
Asylum,  and  afterwards  ably  edited  by  Mr.  Luzerne  Rae, — a  quarterly 
periodical  which  continues  to  the  present  time.  This  is  by  far  the  most 
valuable  publication  connected  with  the  subject  on  which  it  treats  at  present 
in  existence.. 


430  APPENDIX. 

In  1851,  the  teachers  of  the  deaf  and  dumb  in  the  United  States,  and 
others  interested  in  the  education  of  that  class,  assembled  in  convention  at 
the  Connecticut  Institution,  for  the  purpose  of  discussing  matters  of  interest 
connected  with  the  instruction  of  deaf  mutes,  at  which  several  papers  of 
interest  were  read,  and  subsequently  published  in  the  Proceedings  of  that 
body. 

With  a  view  to  the  improvement  of  the  system  of  instruction,  the  direc- 
tors of  the  New  York  Institution  sent  the  Eev.  G-.  Day,  in  1844,  to  examine 
the  different  schools  in  Central  and  Western  Europe,  and  Mr.  H.  Peet,  the 
President  of  the  Institution,  was  despatched  upon  a  similar  mission  in 
1851.  From  the  valuable  Report  of  the  latter,  published  in  the  Thirty- 
third  Annual  Report  on  the  Instruction  of  the  Deaf  and  Dumb,  presented 
to  the  Legislature  of  the  State  of  New  York ;  together  with  such  revisions 
and  additions  as  the  present  census  of  Grreat  Britain  and  Ireland  has  sup- 
plied, we  learn  that  there  are  at  present  in  the  world  194  schools,  with  449 
teachers,  and  about  7000  pupils  receiving  instruction.  Of  these  schools, 
the  first  establishment  of  which  dates  from  that  in  Scotland,  erected  in 
1760,  there  are  in  the  British  Isles,  22  ;  in  France,  44 ;  the  Grerman  States 
and  free  "cities,  28 ;  Austria,  10 ;  Italy,  11 ;  Prussia,  25  ;  Belgium  and 
Holland,  10 ;  Bavaria,  10 ;  Denmark,  Sweden,  and  Norway,  5  ;  Switzer- 
land, 10 ;  Russia  and  Poland,  2  ;  the  United  States  of  America,  13  ;  Ca- 
nada, 1;  Spain,  2;  Portugal,  1;  and  Asia,  2.  Of  the  entire  number,  109 
are  supported  by  the  governments  of  their  respective  countries;  31  by 
voluntary  contributions ;  7  are  of  a  mixed  character ;  23  are  private ;  and 
in  24  instances  the  means  of  support  are  not  stated. 

In  the  seven  Irish  institutions — all  supported  by  voluntary  contributions 
— there  were  in  March,  1851,  as  many  as  232  pupils, — 123  males  and  109 
females;  and  from  the  first  opening  of  the  Claremont  Asylum  in  1816  to 
the  date  of  the  last  census,  1081  pupils  had  received  the  blessings  of  in- 
struction in  our  Irish  institutions.  With  us,  the  period  of  instruction  has 
been,  on  an  average,  five  years,  and  the  "  school  age,"  or  that  during  which 
pupils  are  most  susceptible  of  instruction,  is  from  6  to  15.  It  is  of  great 
importance  that  this  fact  should  be  generally  known,  as  it  is  now  acknow- 
ledged by  the  most  experienced  teachers  of  the  deaf  and  dumb  that  after  a 
certain  age  the  great  majority  of  persons  so  afflicted  are  incapable  of  receiv- 
ing literary  instruction ;  and  this  should  also  stimulate  the  efforts  of  those 
who  advocate  the  claims  which  that  class  have  upon  public  benevolence. 
Some  industrial  arts  are  taught  in  the  Irish  institutions :  it  is,  however,  a 
question  worthy  of  consideration  how  far  it  is  advisable  to  carry  on  handi- 
crafts beyond  a  certain  extent  in  connexion  with  institutions,  as  opposed 
to  the  system  of  apprenticeships.  On  this  subject,  I  may  refer  to  the  Trans- 
actions of  the  recent  Conference,  alluded  to  at  page  429, — a  work  which 
should  be  in  the  hands  of  the  managing  committees  of  all  our  institutions. 


DEAF-DUMBISrESS.  431 

I  may,  however,  add,  that  the  amount  of  industrial  education  afforded  in 
all  establishments  for  the  deaf  and  dumb  should  be  much  more  extensive 
than  it  is  at  present.  As  already  mentioned  at  page  427,  the  Act  for  the 
Relief  of  the  Poor  in  Ireland  makes  some  provision  for  the  education  of  the 
deaf  and  dumb  in  special  establishments  for  that  purpose ;  and  many  of  the 
children  in  the  "  Catholic  Institution"  are  supported  there  by  that  means. 
I  cannot,  however,  but  think  that  the  Board  of  National  Education  should 
provide  some  separate  establishment  for  the  instruction  of  this  class. 

The  system  of  instruction  for  deaf  mutes  consists — first,  of  Signing,  which 
may  be  divided  into  the  employment  of  such  natural,  imitative,  or  descrip- 
tive signs  or  expressions  of  thought  by  gesture  and  pantomime  as  all  mute 
persons  acquire ;  or  those  arbitrary  and  conventional  signs  used  by  teachers 
and  others  in  the  habit  of  communicating  with  the  deaf  and  dumb.  The 
former  are  common  to  all  mutes,  and  vary  but  little ;  the  latter  are  gene- 
rally founded  upon  some  special  plan,  the  method  of  one  teacher  differing 
from  that  of  another, — all  of  which  shows  the  necessity  of  adopting  some 
universal  system  by  which  the  mutes  of  countries  speaking  different  lan- 
guages may  communicate  their  ideas.  The  use  of  pictures,  models,  and 
similar  illustrations  may  be  classed  under  this  head.  Secondly,  Dactology, 
or  finger-writing  by  either  the  double  or  single-hand  alphabet.  The  former 
is  that  generally  taught  in  this  country ;  the  latter,  which  is  chiefly  used 
on  the  Continent  of  Europe,  and  in  America,  seems  to  have  many  advocates 
at  present  in  Great  Britain.  Thirdly,  "Writing  and  Reading.  Fourthly, 
Lip-reading,  by  which  a  mute  understands  what  is  said  by  merely  watching 
the  motions  of  the  lips  of  a  speaker :  those,  howevei",  who  acquire  this 
facility  are  generally  such  as  heard  and  spoke  originally,  but  who,  by  acci- 
dent or  disease,  became  totally  deaf,  and  subsequently  mute.  Fifthly, 
Articulation,  or  the  pronunciation  of  words  and  sentences.  To  what  extent 
the  true  congenital  deaf  person  can  ever  be  taught  to  speak  is  still  unde- 
termined,— only  a  few  of  the  most  intelligent  and  anxious  are  at  all  suscep- 
tible of  such  teaching,  and  even  in  these  the  effort  at  vocalization  is,  from 
want  of  hearing,  harsh  and  inharmonious,  and  seldom  turned  to  much 
account  in  their  intercourse  in  life.  In  most  of  our  schools  in  Great  Britain 
and  Ireland,  the  system  has,  except  in  some  rare  instances,  been  abandoned, 
the  governors  and  teachers  conceiving  that  the  time  spent  in  acquiring  this 
mechanical  form  of  speech  might  be  more  usefully  employed  in  other  de- 
scriptions of  instruction. 

Of  the  industrial  education  of  deaf  mutes  it  is  unnecessary  to  enter  at 
length.  I  believe  there  are  as  many  born  mutes  capable  of  acquiring  a 
practical  knowledge  of  mechanical  and  industrial  arts  as  will  be  found 
among  a  similar  number  of  hearing  and  speaking  persons  in  the  same  rank 
in  life  (see  the  Tables  showing  the  occupations  of  deaf  mutes  in  the  Irish 
Census  Report  for  1851,  p.  11). 


432  APPENDIX. 

No  approximation  to  the  number  of  the  deaf  and  dumb  in  the  habitable 
globe  can  be  made  until  statisticians  have  arrived  at  some  definite  ideas  as 
to  the  amount  of  population  on  the  earth's  surface ;  it  has,  however,  been 
computed  that  there  are  at  least  eight  hundred  and  fifty  thousand  deaf 
mutes  in  the  world,  which  shows  how  universal  and  wide-spread  this  calamity 
is.  In  Europe  and  America,  where,  for  a  number  of  years  past,  quinquen- 
nial or  decennial  enumerations  of  the  population  have  been  made,  the  num- 
ber of  the  deaf  and  dumb  has  been  ascertained  with  tolerable  accuracy.  In 
1830,  Dr.  Schmalz,  in  his  work,  quoted  at  page  43,  published  a  Table  of 
the  number  of  mutes  in  the  population  of  the  different  countries  of  Europe, 
from  which  it  appears  that  they  amounted  to  145,131,  in  a  population  of 
two  hundred  and  fourteen  millions,  or  1  in  every  1474 ;  but  he  does  not 
state  the  authorities  from  which  his  Table  was  compiled.  In  the  Third 
Circular  of  the  Royal  Institution  for  Deaf  Mutes  in  Paris,  issued  a  few 
years  subsequently,  some  Tables  were  published,  in  which  the  number  given 
for  all  Europe  is  only  128,966.  The  most  recent  European  computation 
is  that  by  Dr.  Lachman,  who  estimates  the  number  of  mutes  at  211,585,  or 
1  in  every  1356,  in  a  gross  population  of  287,085,876.  It  is  said,  that 
there  are  but  few  deaf  and  dumb  persons  in  China :  we  know,  however,  so 
little  of  the  true  state  of  that  country,  that  assertions  with  respect  to  its 
population  must  be  received  as  mere  conjectures. 

Tables,  exhibiting  the  numerical  proportion  which  the  deaf  and  dumb 
bear  to  the  rest  of  the  population,  have  been  published  at  different  periods 
during  the  present  century,  for  most  of  the  countries  of  Europe.  Some  of 
these  Tables,  which  show  the  interest  which  the  governments  of  several 
kingdoms  have  taken  in  the  condition  of  that  class  of  the  community,  have 
been  recently  collected  and  published  by  Dr.  Sauveur,  by  order  of  the  Bel- 
gian Government.  His  investigations  were  commenced  in  1885,  and  the 
results,  "  Statistique  des  Sourds-muets  et  des  Aveugles  de  la  Belgique," 
were  published  in  1847,  in  the  "  Bulletin  de  la  Commission  Centrale  de 
Statistique  j"  tome  iii.  Bruxelles :  one  of  those  magnificent  works  brought 
out  under  the  auspices  of  the  President  of  the  Commission,  M.  Quetelet. 

According  to  the  most  recent  Tables,  we  find  that  in  all  Europe,  so  far 
as  authentic  information  can  be  obtained,  the  proportion  of  deaf  mutes  to 
the  population  is  1  in  1593,  a  number  bearing  a  great  similarity  to  the 
Irish  returns.  The  Duchies  of  Luxembourg  and  Vv'urtemburg,  and  the 
kingdoms  of  Tuscany,  Bavaria,  Belgium,  and  Holland,  have  the  fewest,  the 
average  of  these  countries  being  1  in  2209 ',  while  Sardinia,  Norway,  and 
parts  of  Switzerland,  exhibit  the  greatest  number  of  deaf  mutes  in  propor- 
tion to  their  populations,  having  one  in  every  641-9.  In  some  of  the  Swiss 
Cantons  the  proportion  of  the  deaf  and  dumb  to  the  population  is  as  high 
as  1  in  206,  and  in  these  localities  muteism  is  generally  combined  with 
cretinism,  goitre,  or  idiotcy.     The  inhabitants  of  mountain  ranges,  or  coun- 


DEAF-DUMBNESS.  433 

tries  mucli  elevated  above  the  sea  level,  present  many  more  deaf  mutes  in 
proportion  than  low,  flat  countries ;  while  blindness  preponderates  in  the 
latter.  It  would  have  added  to  the  interest,  and  increased  the  value  of 
these  observations,  could  a  table  showing  the  numbers  and  proportions 
of  the  deaf  and  dumb  in  each  country  have  been  given ;  but  the  records  of 
many  are  defective,  and  the  statistics  of  other  countries  are  not  of  suflB.- 
ciently  recent  date  to  afford  a  fair  means  of  comparison ;  for  example,  no 
authentic  account  of  the  number  or  condition  of  the  deaf  and  dumb  in  either 
Spain  or  Portugal  has  appeared  in  print  for  some  years.  But,  in  Spain, 
according  to  information  derived  from  private  sources,  there  are  at  present 
said  to  be  12,000  mutes,  or  1  in  every  1500  of  the  population. 

Owing  to  the  impossibility  of  determining  the  question  of  congenital 
deafness  at  a  very  early  period  of  life,  great  difficulties  must  always  lie  in 
the  way  of  ascertaining  the  exact  amount  of  the  mutes  in  any  country;  so 
that  in  any  table  of  ages  for  this  class  we  do  not  find  a  single  individual 
under  eighteen  months,  few  under  two  years.  If  to  the  census  returns  of 
each  country  we  add  three  per  cent,  more  congenital  deaf  and  dumb,  we 
shall  approach  nearer  the  truth.  In  this  calculation  I  am  aware  I  differ 
from  some  eminent  authorities,  but,  in  arriving  at  this  conclusion,  other 
disturbing  causes  should  be  taken  into  account,  as,  for  instance,  the  number 
of  persons  who  must  be  erroneously  returned  as  "deaf  and  dumb,"  pro- 
bably from  misconception  of  the  meaning  of  the  query.  Among  the  sources 
of  error  may  be  enumerated  those  of  returning  children  who  had  not  at  the 
ordinary  period  begun  to  speak ;  cases  of  defective  articulation  and  aggra- 
vated hesitations  ;  and  instances  of  paralysis  occurring  in  adults  or  persons 
in  advanced  life ;  of  none  which  should  properly  come  under  the  head  of 
muteism,  either  congenital  or  acquired. 

The  information  derived  from  parents  or  friends,  as  to  whether  the  per- 
son was  born  deaf  and  dumb,  must  be  received  with  caution ;  as,  in  a  great 
number  of  instances,  the  query  will  be  answered  in  the  negative, — the  rela- 
tives and  attendants  being  generally  unwilling  to  admit  the  fact  of  congeni- 
tal defect,  and  stating  that  they  were  sure  the  child  heard  well  until  it  was 
twelve,  fifteen,  or  eighteen  months  old;  although  it  is  not  always  possible, 
without  special  attention  being  directed  to  the  subject,  to  form  a  decided 
opinion  as  to  the  amount  of  hearing  possessed  by  an  infant  of  such  tender 
age.  Upon  a  strict  inquiry,  however,  it  will  generally  be  found  that  the 
premises  do  not  warrant  the  conclusion  that  complete  deafness  did  not  exist 
at  birth,  the  circumstances  related  being  usually  those  in  which  the  child 
noticed  general  vibration,  such  as  that  produced  by  a  piano,  &c.,  and  not 
distinct  sounds,  like  those  of  a  human  voice ;  and  the  more  intelligent  the 
class  the  more  likely  are  these  opinions  to  prevail.  All  mutes  are  not 
totally  devoid  of  hearing;  and,  moreover,  the  visual  power  in  that  class 
being  at  a  very  early  age  called  into  special  actionj  attention  is  often  mis- 

28 


434  APPENDIX. 

taken  for  hearing.  There  is  scarcely  a  case  of  muteism  in  a  child  under 
five  years  of  age  in  the  upper  classes,  on  which  I  am  consulted,  that  the 
relatives  do  not  come  prepared  with  evidence  to  prove  that  the  child  heard 
well  for  more  than  a  year  after  birth, — in  fact,  until  their  attention  was 
specially  directed  to  the  state  of  its  hearing.  Physiologists  have  not  de- 
cided at  what  age  an  infant  first  hears,  and  in  what  order  its  senses  are 
developed  or  called  into  action.  Taste,  with  some  touch,  and  a  certain 
amount  of  muscular  motion,  are  put  forth  in  the  act  of  sucking,  immedi- 
ately after  birth,  in  all  mammary  animals.  The  earliest  directed  muscular 
action  of  the  infant  is  that  of  the  hand  pressed  against  the  nurse's  breast, 
but  the  period  at  which  this  occurs  is  very  variable.  Vision  seems  to  be 
perfect  at  birth ;  and  even  before  a  child  has  sucked  it  is  attracted  by  light, 
and  evidently  turns  to  the  blaze  of  a  fire  or  candle.  An  intelligent  child 
will  recognise  its  nurse  in  from  six  weeks  to  two  months,  after  which  it  will 
begin  to  smile  at  those  it  is  accustomed  to.  During  the  third  month,  chil- 
dren appear  to  be  conscious  of  sounds,  and  in  the  fourth  exhibit  an  appre- 
ciation of  particular  sounds,  such  as  chirping,  whistling,  &c.,  &c.  :  after 
that  period  they  begin  to  recognise  the  voice,  and  from  the  fourth  to  the 
sixth  month  is,  perhaps,  the  earliest  period  when  an  opinion  can  be  formed 
as  regards  the  hearing  of  an  infant;  but  the  idea  of  deafness  never  having 
presented  itself,  it  is  seldom  until  after  the  twelfth  month  (unless  there 
are  other  mutes  in  the  family)  that  the  friends  or  attendants  begin  to  per- 
ceive that  the  child  does  not  hear.  After  the  fifth  or  sixth  month,  infants 
recognise  particular  sounds  and  distinguish  the  voice  of  individuals.  This 
latter  faculty  is  in  some  degree  dependent  upon  the  development  of  the 
teeth,  which,  to  a  certain  extent,  influences  the  sense  of  hearing,  as  already 
stated  at  page  309.  Anatomists  say  that  at,  and  even  for  some  time  after, 
birth,  the  tympanum  and  the  meatus  are  filled  with  mucus :  the  former 
■cavity  is  then  so  narrow  that  the  quantity  of  fluid  it  contains  must  be  very 
small ;  and  in  the  latter  it  is  more  likely  to  be  some  of  the  liquor  amnii 
which  remains  in  the  external  auditory  canal  than  mucus.  The  next  de- 
velopment is  a  combination  of  tact,  touch,  and  directed  muscular  motion, 
as  shown  first  in  grasping  objects  placed  within  reach  of  the  hand,  and  then 
directing  them  to  the  mouth,  which  will  occur  very  early  in  life.  There  is 
no  sense  so  variable  in  its  development  as  speech.  Some  children  begin  to 
speak  at  twelve  to  eighteen  months,  others  not  till  after  the  second  year : 
some  pronounce  distinctly  at  two  years,  and  others  not  until  nine  or  ten  : 
a  few  not  at  all.  Family  peculiarity  seems  to  influence  the  development  of 
speech,  and  also  congenital  malformation  of  the  tongue  and  mouth.  Mo- 
thers and  nurses  have  an  idea  that  when  a  child  does  not  speak  at  the  usual 
time,  it  is  tongue-tied,  and  among  the  lower  orders  this  impression  is  very 
popular.  True  tongue-tie,  in  which  the  fraenum  extends  to  the  lip,  or  pro- 
jects over  it,  is,  however,  very  rare. 


DEAF-DUMBXESS.  435 

Until  the  inquiry  made  under  tlie  Census  Commission  of  1851,  no  means 
■worthy  of  credit  were  instituted  to  ascertain  the  exact  number  of  deaf  mutes 
in  the  British  Isles.  Computations  had  been  made,  and  vague  conjectures 
puljlished  upon  the  statistics  of  deaf-dumbness;  but  as  the  mode  in  which 
the  inquiries  were  conducted  had  not  been  explained,  nor  the  materials  at 
the  disposal  of  the  individuals  who  undertook  them  communicated  to  the 
public,  no  certainty  could  be  felt  as  to  their  accuracy ;  and  moreover,  it  is 
manifest  that  statistical  investigations  for  an  entire  kingdom  can  only  be 
effectually  undertaken  and  properly  carried  out  by  the  state.  The  census 
of  Great  Britain  not  being  yet  published,  I  am  unable  to  state  the  precise 
number  of  deaf  mutes  in  England,  Scotland,  and  "Wales ;  but  taking  the 
population  at  20,793,552,  according  to  the  abstract  of  the  census  of  1853, 
and  estimating  the  former  class  at  1  in  1500,  in  round  numbers,  I  think 
14,000  may  be  set  down  as  the  total  of  the  deaf  and  dumb  in  that  country. 
How  far  the  elevated  districts  of  Scotland  and  Wales  may  alter  this  calcu- 
lation remains  to  be  seen. 

In  Ireland,  in  a  population  of  6,553,210,  there  were  in  March,  1851,  as 
many  as  4151  true  deaf  and  dumb  persons,  or  1  in  every  1579  of  the 
community.  In  a  country  like  this,  completely  insulated,  limited  in  ex- 
tent, and  possessing  great  sameness  on  its  surface,  one  would  not  expect 
that  the  proportion  should  alter  very  much  in  the  different  provinces  and 
counties,  still  we  found  the  following  varieties  : — in  Leinster,  1  in  1794 ; 
Connaught,  1  in  1689;  Ulster,  1  in  1486;  and  in  Munster,  1  in  1469. 
Deaf-dumbness,  arising  from  all  causes,  prevails  most  in  the  rural,  and  least 
in  the  civic  portions,  or  those  towns  whose  inhabitants  amount  to  2000  and 
upwards.  Thus  there  are,  comparatively,  fewer  cases  in  proportion  to  the 
population  to  be  found  in  the  towns  of  Drogheda,  Carrickfergus,  Galway, 
and  Belfast,  and  the  cities  of  Cork  and  Dublin,  the  average  of  these  places 
being  1  in  2586,  than  in  other  localities.  Generally  speaking,  the  flat 
campaign  counties,  such  as  Roscommon,  Westmeath,  Dublin,  Meath,  and 
Kildare,  present  the  fewest  cases,  their  average  being  1  in  1980;  while 
Mayo,  Limerick,  Donegal,  Waterford,  and  "Wicklow,  and  also  Tipperary, 
Tyrone,  and  Fermanagh,  the  former  lying  chiefly  on  the  sea-coast,  and  the 
majority  presenting  mountain  ranges,  have  a  proportionally  greater  number 
of  deaf  and  dumb  than  the  remaining  counties,  their  average  being  1  in 
1338 ;  and  in  Wicklow,  which  is  both  maritime  and  mountainous,  the  pro- 
portion is  as  high  as  1  in  1192.  Leitrim,  Clare,  Down,  and  Antrim,  are 
also  high. 

In  the  United  States  of  America,  according  to  the  census  of  1850,  there 
were,  in  a  population  of  19,381,591  icliite  persons,  9422  mutes,  or  1  in 
every  2057 ;  and  among  a  free  colored  population  of  251,205,  there  were 
only  96,  or  1  in  2616.  In  the  slave  population  it  is  said  that  the  propor- 
tion of  deaf  mutes  is  very  much  less  than  either  the  free  colored  or  the  free 


436  APPENDIX. 

white,  beiug  as  low  as  1  in  6552,  This  latter  statement  requires  confirma- 
tion ;  the  census  schedules  being  filled  by  the  owners  or  overseers  of  estates, 
and  many  of  the  deaf  and  dumb  being  still  useful  hands,  their  defect  might 
be  overlooked.  If,  as  stated  in  the  American  returns,  the  black  population, 
both  slave  and  free,  have  fewer  deaf  and  dumb  among  them  than  the  white, 
it  rather  militates  against  the  doctrine  of  consanguinity  of  parents  leading 
to  muteism  in  offspring. 

This  question  leads  us  to  the  consideration  of  another,  of  much  ethnolo- 
gical interest,  but  on  which,  as  yet,  sufficient  observations  have  not  been 
made, — that,  as  to  whether  race  or  climate  influences  the  production  of  con- 
genital muteism.  In  order  to  come  at  some  conclusion  on  the  latter  subject, 
we  registered  (in  Ireland)  the  family  names  of  1671  persons  born  deaf  and 
dumb ;  and  of  these  it  was  found  that  1198  were  Irish,  352  English,  and 
121  Scotch.  To  arrive,  however,  at  any  fair  deduction  from  this  registra- 
tion, we  should  also  possess  information  as  to  the  proportion  of  the  English, 
Scotch,  and  Irish  surnames  generally  throughout  the  country. 

From  a  communication  with  which  I  have  been  favored  by  Mr.  Peet,  it 
appears  that  "there  is  no  impediment  in  the  education  of  colored  deaf 
mutes  in  th'e  Northern  States,  escept  the  ignorance  or  indifference  of  their 
parents."  There  were  three  black  deaf  mutes  in  the  American  institutions 
last  year. 

Many  questions  of  interest  connected  with  the  deaf  and  dumb  have  been 
propounded  at  different  times,  and  vague  and  unsatisfactory  conjectures 
offered  for  their  solution.  Several  of  these  I  am  now  able  to  answer  from 
the  results  of  the  minute  inquiry  instituted  with  respect  to  their  condition 
in  Ireland;  an  inquiry  to  which  the  circumstances  of  this  country,  the 
admirable  organization  of  the  police  force,  and  the  great  willingness  on  the 
part  of  the  people  to  afford  the  necessary  information,  were  particularly 
favorable.  The  strict  analysis  made  here  of  this  class  of  permanent  disease 
has  afforded  a  return  far  more  faithful  and  minute  than  any  heretofore  pre- 
sented for  other  countries.  I  may  mention,  that,  where  any  difficulty  arose 
with  respect  to  the  true  physiological  or  pathological  condition  of  a  case, 
the  examination  of. a  medical  man  was  had  recourse  to;  and  it  is  highly 
creditable  to  the  country  practitioners  of  Ireland,  to  state  that,  although 
the  opinion  was  requested  gratuitously,  it  was  almost  invariably  given  in  the 
cause  of  science  and  humanity. 

The  following  list  of  questions  relating  to  the  deaf  and  dumb,  which  we 
employed  in  Ireland,  may  assist  future  investigators  in  this  hitherto  insuffi- 
ciently explored  subject,  and  from  it  may  be  seen  upon  what  data  the  various 
tables  accompanying  the  census  memoir  were  constructed : — 

Whether  the  person  was  born  deaf  and  dumb,  or  became  so  afterwards  ? 

If  born  deaf  and  dumb,  to  what  cause  such  defect  is  attributed  by  the 


DEAF-DTJMBXESS.  437 

friends  or  relatives;  wliether  to  fright,  hereditary  predisposition,  or  the  near 
relationship  of  parents,  such  as  the  intermarriage  of  cousins,  &c.  ? 

If  the  persons  became  deaf  and  dumb  since  birth, — at  what  age,  and  to 
what  disease  or  other  cause  has  such  been  attributed  ? 

Whether  any  other  members  of  the  family,  parent  or  parents,  or  grand- 
parents, uncles,  aunts,  or  cousins,  have  been  deaf  and  dumb  ? 

What  other  members  of  the  family,  living  or  dead,  such  as  brothers  or 
sisters,  were  afflicted  with  deaf-dumbness,  and  if  so,  a  statement  of  the 
number  and  particulars? 

Whether  the  person  is  educated,  and  if  so,  where  and  by  what  means 
such  education  has  been  acquired  ? 

The  mute  person's  position  in  the  family,  whether  first,  second,  or  third 
child,  in  a  family  of  so  many,  both  living  and  dead  ? 

Other  inquiries,  arising  in  particular  cases,  out  of  the  answers  to  the 
foregoing,  were  also  made  with  respect  to  the  nature  of  the  fright  experi- 
enced either  by  the  mother  or  the  mute  offspring;  whether  the  hereditary 
taint  came  through  the  male  or  female  parent ;  what  was  the  cause  of  death 
of  any  of  the  mute  relatives ;  whether  idiotcy,  paralysis,  or  other  diseases 
or  malformation  coexisted ;  and,  in  case  of  the  marriage  of  mutes,  what 
had  been  the  result  to  the  children,  &c.  Registries  founded  on  the  fore- 
going queries  should  be  preserved  at  all  institutions  for  the  deaf  and  dumb. 

True  and  uncomplicated  muteism  may  be  divided  into  two  classes.  The 
first  is  congenital,  or  that  with  which  the  patient  is  born, — it  is  either  func- 
tional or  organic ;  in  the  latter  case  it  usually  arises  from  some  defect  of 
organization,  either  in  the  mechanical  apparatus  of  hearing,  the  auditory 
nerve,  or  in  the  great  nervous  centre  itself,  the  causes  of  which  are  speci- 
fied under  the  head  of  malformations  of  the  internal  ear  at  page  302.  The 
second  is  that  proceeding  from  disease  acquired  subsequent  to  birth,  but 
which  occurred  so  early  in  life  that  speech  had  never  been  fully  attained,  or, 
from  the  deafness  being  so  intense,  that  speech  was  either  entirely  lost  or 
greatly  impaired  in  after  life.  In  the  latter  class  the  acquired  disease,  par- 
ticularly if  it  occurs  within  the  first  few  years  of  life,  reduces  the  patient 
to  the  position  of  a  mute  equally  with  the  former,  and  so  places  both  in  the 
same  division  in  a  social  and  statistical  point  of  view ;  but,  as  there  are 
many  topics  of  scientific  interest  appertaining  specially  to  each  class,  they 
should  be  kept  separate,  and  the  calculations  belonging  to  each  given  in  dis- 
tinct columns  in  the  several  tables  relating  thereto. 

It  must  not  be  supposed  that  under  the  foregoing  general  division  of 
congenital  and  acquired  deafness,  we  can  include  or  define  all  the  deaf 
mutes  of  the  community.  There  are  certain  complications  which  have  not 
heretofore  been  much  investigated,  but  which  were  so  carefully  considered 
in  the  Irish  census  of  this  class,  that  the  results  which  we  obtained  are 


438  APPENDIX. 

likely  to  remain — until  still  more  extensive  inquiries  are  iostituted — illus- 
trations of  the  laws  or  principles  which  regulate  these  complications. 

The  first  great  division  is  into  the  deaf  and  dumb ;  and,  the  dumb  but 
not  deaf.  Of  the  total  4814  Irish  returns,  329  were  erroneous;  and  it  was 
found,  upon  instituting  a  minute  inquiry  into  the  circumstances  of  each  of 
the  remaining  4585  mutes,  that  334  were  dumb,  but  not  deaf.  Dumbness 
may  be  either  congenital  or  acquired ;  of  the  latter  I  have  given  an  exam- 
ple at  page  327.  The  majority  of  the  "dumb  only"  proved,  upon 
examination,  to  be  either  idiotic,  paralytic,  or  both ;  they  could  hear,  but 
did  not  speak,  or,  if  they  made  any  attempt  thereat,  it  was  so  inarticulate, 
either  from  defect  in  the  organs  of  speech,  or  inability  of  apprehension, 
that  they  were  incapable  of  making  themselves  understood.  Their  affection, 
like  that  of  the  "  deaf  and  dumb,"  was  chiefly  congenital.  Heretofore  it 
has  been  generally  believed  that  defect  of  speech  is  solely  and  invariably 
the  result  of  impaired  or  total  loss  of  hearing.  Nevertheless,  it  appears 
from  the  faithful  report  of  those  medical  men  who  examined  and  inquired 
into  the  cases,  as  well  as  from  my  own  personal  observation  of  some  of 
those  included  in  the  returns,  that  instances  of  simple  and  uncomplicated 
idiopathic  dumbness,  independent  of  deafness,  although  rare,  really  do  exist. 
The  details  of  some  of  these  cases  are  embodied  in  our  report,  which  has 
not  only  materially  added  to  the  general  and  vital  statistics  of  this  country, 
but  has  greatly  increased  our  stock  of  knowledge  upon  the  subject  of  miite- 
ism  generally,  and  has  thus  enlarged  the  boundaries  of  science,  and  con- 
ferred a  benefit  upon  humanity.  The  total  number  of  "dumb  only," 
without  being  either  paralytic  or  idiotic,  was  131 :  the  dumb  with  paralysis 
numbered  45 ;  the  idiotic  dumb  amounted  to  115,  and  those  afl[licted  with 
both  paralysis  and  idiotcy  to  43. 

Among  the  cases  of  persons  dumb  only,  and  not  otherwise  affected,  is 
that  of  a  boy  in  the  city  of  Dublin,  aged  10,  whom  I  have  often  examined. 
He  is  neither  deaf,  paralytic,  idiotic,  nor  deformed.  He  is  intelligent,  and 
understands  what  is  said  to  him ;  but  his  manner  is  excited,  and  he  has  a 
peculiar  anxious  and  restless  look,  and  is  rather  irritable,  and  very  intolerant 
of  restraint.  The  organs  of  speech  are  well  formed,  as  are  also  those  of 
hearing,  so  far  as  can  be  observed;  but  he  makes  no  attempt  at  articulation, 
or  the  pronunciation  of  words.  When  he  wishes  to  attract  attention  he 
utters  a  loud,  sharp,  bark-like  sound. 

An  instance  similar  to  the  foregoing,  in  a  boy  seven  years  of  age,  has 
been  thus  reported  on  by  Professor  Doherty,  of  Galway  :  "  He  is  dumb,  or 
very  nearly  so,  but  not  deaf;  on  the  contrary,  he  is  very  quick  of  hearing, 
has  acute  sight,  and  his  understanding  is  by  no  means  blunt.  His  head, 
though  small,  presents  no  peculiar  deformity ;  and  he  protrudes  his  tongue 
to  the  usual  extent.  He  understands  what  is  said  to  him,  will  go  of  a 
message,  and  evidently  possesses  imitative  powers.     But  though  far  from 


DEAF-DUMBNESS.  439 

being  an  idiot,  it  is  quite  evident  that  his  mental  powers  are  not  perfect ; 
there  is  a  restlessness  depicted  in  his  face,  and  extreme  energy  in  his  move- 
ments, and  I  rather  think  a  mischievousness  in  bis  acts.  I  am,  on  the 
whole,  inclined  to  view  his  case  as  similar  to  those  described  by  Woodward 
in  the  '  American  Journal  of  Medical  Sciences/  and  to  regard  it  as  a  pecu- 
liar form  of  insanity/' 

Jussieu  has  given  an  account  of  a  Portuguese  girl,  fifteen  years  of  age, 
who  was  born  without  a  tongue.. — (On  this  subject  see  Paris  and  Fontblan- 
ques's  Medical  Jurisprudence,  vol.  i.  p.  370.) 

Dr.  Purdon,  of  Killeshandra,  has  reported  upon  some  instances,  dumb 
only,  in  the  county  Cavan, — one,  a  female,  aged  40,  "can  hear  perfectly 
well,  but  has  no  power  over  the  muscles  of  her  mouth,  so  that  she  cannot 
drink  without  throwing  back  her  head,  neither  was  she  able  to  suck  when 
an  infant.  She  also  suffers  from  partial  paralysis  of  the  tongue  itself, 
which  she  cannot  protrude  beyond  the  lips,  nor  elevate  to  the  palate, 
although  she  is  not  tongue-tied.  In  other  respects  she  is  well  formed, 
strong,  and  active.  '  No'  is  the  only  word  she  can  pronounce."  A  female, 
aged  16,  "  is  not  deaf,  but  cannot  attempt  to  pronounce  any  word.  The 
tongue  is  well  shaped,  can  be  protruded,  and  bent  downwards,  but  not  ele- 
vated ;  she  has  strabismus  of  both  eyes,  but  has  no  defect  in  the  muscles 
of  the  mouth.  The  dumbness  appears  to  be  caused  by  some  original  mal- 
formation of  the  brain."  "  A  boy,  aged  12,  can  pronounce  the  words  'da' 
and  '  ma,'  but  no  others.  He  is  good-looking,  intelligent,  and  has  a  well- 
developed  muscular  system ;  his  tongue  is  well  shaped,  but  adheres  too 
closely  to  the  floor  of  the  mouth;  he  has  no  power  to  protrude  it  beyond  his 
lips,  nor  elevate  it  tov/ards  his  nose;  the  muscles  of  the  lips  are  paralyzed; 
his  hearing  is  perfect."  A  male,  aged  20,  "can  hear  perfectly  well;  is 
not  idiotic,  but  passionate ;  he  can  say  '  ay'  and  '  no'  very  well ;  his 
tongue  is  rather  thick,  and  misshapen  at  the  point,  but  he  can  whistle ;  I 
found  him  quick  in  comprehending,  and  answering  my  questions  by  gesti- 
culations. 

Dr.  Walsh,  of  Ballinakill,  has  afforded  the  following  return  upon  the  ease 
of  a  man,  aged  20 :  "  He  is  completely  dumb,  seemingly  not  capable  of 
giving  expression  to  even  inarticulate  sounds;  his  hearing  is  acute  and 
correct,  and  he  is  in  no  way  guided  by  observing  the  lips  of  the  speaker; 
he  is  an  intelligent,  well-formed,  agricultural  laborer;  his  tongue  appears 
shorter  than  natural,  and  he  cannot  protrude  it  beyond  the  lower  lip,  but 
can  move  it  from  side  to  side  with  freedom ;  he  has  no  cerebral  disease." 

These  cases  will  serve  to  explain  the  meaning  attached  to  the  term  "dumb, 
not  deaf,"  or  "-dumb  only." 

In  many  instances  of  defective  articulation,  as  well  as  severe  stuttering, 
and  of  partial  muteism— a  disease  not  yet  well  described  by  authors — there 


440  APPENDIX. 

is  a  peculiar  narrowness  and  an  unnatural  height  of  the  palate  immediately 
behind  the  upper  incisor  teeth. 

Of  the  4151  true  deaf-dumb  afforded  by  the  Irish  returns,  159  were  also 
either  idiotic  or  paralytic ;  3325  were  born  deaf,  and  consequently  remained 
dumb,  but  had  no  other  mental  or  bodily  defect;  400  became  deaf  mutes 
after  birth,  by  accident  or  disease,  or  in  the  proportion  of  1  to  11  of  the 
former.  In  126  instances,  notwithstanding  that  great  pains  were  taken  to 
acquire  the  necessary  information,  it  was  not  possible  to  find  out  whether 
the  disease  was  congenital  or  acquired.  They  might  be  divided  according  to 
the  former  ratio.  The  general  proportion  of  those  who  lose  their  hearing 
after  birth  is  said  to  be  about  1  in  10,000.  In  Ireland,  we  find  that  only 
1  in  12,181  lose  their  hearing  to  such  an  extent,  or  so  early  in  life  as  sub- 
sequently to  become  mute. 

Comparing  the  congenital  with  the  acquired  cases,  we  found  some  remark- 
able differences  caused  by  localities.  In  the  former  class,  the  proportions 
were  1  in  2115  in  the  civic,  and  1  in  every  1760  in  the  rural;  whereas,  in 
the  latter,  the  reverse  obtained — the  acquired  being  in  the  proportion  of  1 
in  9104  in  the  civic,  and  1  in  13,107  in  the  rural — congenital  deafness 
existing  most  amongst  the  rural  population,  and  that  acquired  after  birth 
prevailing  most  in  crowded  cities  and  towns,  where  children  and  young  per- 
sons are  particularly  exposed  to  accidents,  scrofulous  affections,  and  dele- 
terious influences  arising  from  density  of  population,  unwholesome  food, 
impure  air,  and  insufl&cient  sewerage.  Moreover,  the  populations  of  cities 
and  towns  being  in  great  part  recruited  by  immigration  from  the  rural  dis- 
tricts, the  deaf  and  dumb  are  more  likely  to  remain  in  their  native  homes 
than  those  possessing  speech  and  hearing. 

It  has  been  well  observed,  that  man,  though  by  organization  and  intellect 
able  to  exist  in  all  latitudes,  is  not  completely  proof  against  the  influence  of 
climate,  nor  can  he  escape  those  maladies  which  arise  from  the  action  of 
physical  causes  peculiar  to  certain  localities.  In  Switzerland,  where  we 
find  the  greatest  number  of  deaf  mutes,  compared  with  its  population,  in 
any  known  country,  the  prevalence  of  scrofula  (a  disease  which  may,  I  be- 
lieve, be  induced  by  circumstances  independent  of  hereditary  taint),  as  well 
as  the  miserable  condition  of  a  large  portion  of  the  population,  who  are 
located  in  low,  damp  valleys;  who  live  in  comfortless  dwellings,  with  but 
little  light  or  heat;  who  seldom  taste  animal  food,  but  subsist  chiefly  on 
milk  and  farinaceous  materials,  and  drink  water  derived  from  melted  snow, 
— it  is  not  to  be  wondered  that  deaf  muteism,  as  well  as  goitre  and  cretinism, 
are  so  frequent.  Belgium,  on  the  contrary,  as  has  been  remarked  by  Dr. 
Sauveur,  contains  the  least  proportion  of  deaf  mutes,  and  this  he  accounts 
for  by  its  flatness,  and  the  great  fertility  of  its  soil ;  in  addition  to  which, 
the  poorer  classes,  among  whom  deaf  muteism  is  most  frequently  found,  are 


DEAF-DUMBNESS.  441 

always  able,  either  by  labor  or  public  charity,  to  provide  the  necessaries  of 
life,  as  well  as  care  and  medical  relief  in  case  of  sickness. 

With  respect  to  the  sexes  of  the  deaf  and  dumb,  some  questions  of  in- 
terest have  arisen.  In  accordance  with  one  of  those  immutable  laws  which 
appear  to  govern  mankind  in  all  countries,  more  males  are  born  than  females ; 
but  as  in  the  first  years  of  life  more  boys  die  than  girls,  the  sexes  soon 
become  equalized,  and  subsequently  there  is  in  every  population  an  excess 
of  women  over  men.  Yet  the  proportion  of  male  deaf  mutes  from  all  causes 
exceeds  the  female  considerably,  but  it  differs  somewhat  in  the  two  great 
classes  of  congenital  and  acquired.  According  to  our  Irish  investigations, 
the  proportions  were  100  males  to  74-61  females  in  the  former;  and  100 
males  to  91*46  females  in  the  latter.  It  must,  however,  be  remarked,  that, 
at  the  time  these  investigations  were  conducted,  there  was  rather  an  undue 
proportion  of  females  in  this  country. 

Writers  have  asserted,  that  the  organs  of  speech  in  deaf  mutes  are  either 
malformed,  or,  owing  to  want  of  exercise,  remain  undeveloped ;  that  the 
tongue  is  short,  thick,  and  only  suited  for  chewing  and  swallowing ;  that  the 
voice  is  rough  and  nasal,  the  gums  very  irregular;  that  the  uvula  is  also 
deformed,  and  often  turned  to  one  side;  that  the  chest  is  narrow,  and  the 
lungs,  from  want  of  sufficient  play  and  the  ordinary  use  as  in  speaking,  are 
very  liable  to  tubercle,  and  hence  the  greater  mortality  of  the  deaf  and 
dumb  before  the  end  of  the  second  decade  of  life.  Such,  however,  has  not 
been  my  observation  or  experience  of  this  disease,  unless  when  complicated 
with  idiotcy,  paralysis,  or  other  mental  or  bodily  defects ;  cases  of  that 
nature  being  the  exceptions  to  the  rule,  and  complications  of  true  congenital 
muteism.  The  voice  is  inharmonious  and  defective  in  modulation,  because 
the  persons  so  affected  do  not  hear ;  it  is,  indeed,  very  peculiar,  so  much  so, 
that  those  in  the  habit  of  examining  deaf  and  dumb  children  will,  from  the 
tone  of  voice,  be  generally  able  to  pronounce  with  certainty  upon  the  defect. 
With  respect  to  the  pulmonary  affection,  it  is  more  likely  to  have  been 
induced  by  the  presence  of  scrofula,  the  most  frequent  cause  of  muteism, 
than  by  quiescence  of  the  lungs. 

The  causes  of  muteism  may  be  divided  into  the  proximate  and  the  remote; 
the  former  appertaining  to  the  individual  affected — the  latter  chiefly  de- 
rived through  the  parentage.  Regarding  the  former  or  immediate  cause,  it 
is,  as  already  stated  at  page  437, — original  organic  defect,  usually  some 
malformation  of  the  organ  of  hearing,  owing  to  arrest  of  development ;  or, 
it  may  be,  acquired  disease. 

Three  special  causes  seem  to  influence  the  production  and  propagation  of 
muteism  :  fright  experienced  by  the  mother  while  pregnant ;  family  pecu- 
liarity, or  hereditary  taint;  and  too  close  consanguinity,  or  the  intermarriage 
of  near  relatives. 

The  most  popular  opinion  with  respect  to  the  cause  of  deaf-dumbness  is 


442  APPENDIX. 

that  of  fright  experienced  by  the  pregnant  mother;  and  in  this  disease  the 
same  circumstances  are  related  as  those  which  are  adduced  to  account  for 
hare-lip,  club-foot,  idiotcy,  nsevi,  decrepitude,  or  other  congenital  malfor- 
mations or  arrest  of  development,  consisting  generally  of  some  shock  or 
mental  emotion,  seeing  a  disgusting  object,  meeting  a  mute  person,  or  being 
strongly  impressed  with  some  superstitious  dread.  How  far  women  preg- 
nant at  the  time  of  the  shock  or  impression  are  so  susceptible  of  such  as  to 
affect  the  growth  or  appearance  of  the  foetus,  is  by  most  educated  persons 
considered  questionable,  and  is  by  many  altogether  denied.  There  have 
been,  however,  well-authenticated  facts,  ever  since  the  days  when  Laban 
placed  the  striped  rods  before  the  ewes  and  female  cattle,  in  order  that  they 
might  produce  mottled  offspring,  down  to  the  present  time, — to  establish 
the  circumstance  of  maternal  impressions  affecting  the  children.  One  of  the 
most  remarkable  of  these  is  an  instance  related  by  Malblanche,  of  a  woman, 
who,  having  gone  during  the  early  months  of  her  pregnancy  to  see  a  man 
broken  on  the  rack,  felt  a  sudden  and  severe  shock ;  and  her  child,  when 
born,  presented  the  curious  anomaly  of  dislocation  of  all  the  joints  of  its 
extremities;  and  it  was  also  idiotic. 

Among  the  predisposing  causes  of  muteism,  the  too  close  consanguinity 
of  parents  may  be  looked  upon  as  paramount.  Many  conjectures  have  been 
offered  upon  this  subject,  but  the  question  has  been  set  at  rest  by  the  results 
of  the  Irish  census.  From  the  delicacy  attending  this  inquiry,  the  an- 
swers must  be,  to  a  certain  degree,  deficient ;  still,  out  of  the  deaf  and  dumb 
returns,  from  all  causes,  we  procured  the  particulars  of  154  instances  in 
which  the  parents  were  related  in  the  degrees  of  first,  second,  or  third 
cousins.  The  result  of  these  intermarriages  was  100  cases — 86  congenital, 
and  6  acquired — of  one  mute  in  a  family;  4  of  these  were  dumb  only;  and 
4  were  dumb  and  idiotic.  In  34  families,  where  the  parents  were  related, 
two  children  were  deaf  and  dumb,  in  only  one  instance  of  which  the  disease 
occurred  after  birth.  There  were  14  instances  where  three  mutes  were 
born  in  families  so  circumstanced;  and  3  where  four  in  each  family  were 
deaf  and  dumb.  The  parents  were  also  closely  related  in  instances  where 
six  and  seven  in  a  family  were  similarly  afflicted. 

Deaf  muteism  frequently  exists  among  several  members  of  the  same 
family,  from  2  to  as  many  as  even  9.  Sometimes  all  the  mutes  are  males, 
and  all  the  hearing  children  females,  and  sometimes  the  reverse  occurs ;  in 
some  cases  the  result  of  every  alternate  birth  is  mute,  and  in  others  only 
every  third  child.  Our  Irish  returns  afford  the  most  accurate  information 
on  this  and  similar  subjects  connected  with  the  deaf  and  dumb  which  have 
yet  been  obtained.  Of  2962  instances,  of  uncomplicated  congenital  muteism, 
2512  were  cases  of  single  mutes  in  each  family,  the  sexes  being  in  the  pro- 
portion of  100  males  to  73  females,  and  of  these  by  far  the  greater  propoi-- 
tion  were  first  children.     In  each  of  287  families  there  were  two  mute 


DEAF-DUMBNESS.  443 

children,  of  wbom  both  were  males  in  97  instances;  both  females  in  48;  and 
a  male  and  female  in  142.  In  127  families  there  were  three  mute  children  in 
each;  in  18  of  these  cases  they  were  all  males;  in  14,  all  females;  in  42, 
there  were  2  males  and  a  female;  and  in  53,  a  male  and  2  females. 
Thirty-three  instances  presented  of  four  mute  children  born  of  the  same 
parents,  the  combination  of  sexes  being  2  males  and  2  females  in  13  cases; 
a  male  and  3  females  in  7;  3  males  and  a  female  in  6;  all  males  in  5,  and 
all  females  in  2  cases.  Eight  families  had  each  five  mutes;  in  4  of  these 
the  sexes  were  2  males  and  3  females;  in  2  all  males;  in  one  family  4 
males  and  a  female ;  and  in  another  3  males  and  2  females.  In  3  in- 
stances there  were  six  mutes  in  the  same  family;  in  2  of  these  there  were 
2  males  and  4  females ;  and  in  the  third  the  sexes  were  equal ;  these  occurred 
in  families  of  7,  8,  and  9  children.  One  instance  occurred  in  which  seven 
children,  all  females,  were  born  deaf  and  dumb,  in  a  family  of  13.  In  one 
instance  of  9  in  a  family,  eight  were  mute, — 5  males  and  3  females. 
Families  consisting  of  5,  6,  and  7  children  presented  the  greatest  number  of 
mutes.  In  one  instance  two  mute  children,  one  the  tenth,  the  other  the 
the  last,  occurred  in  a  family  of  29,  all  born  of  the  same  parents;  the 
twenty -ninth  child,  now  aged  57,  is  still  living  in  the  County  of  Cork. 

It  has  been  asked  whether  the  ages  of  the  parents  in  any  way  influence 
the  production  of  congenital  muteism,  but  as  yet  we  have  no  means  of  de- 
termining this  question,  in  a  sufiicient  number  of  instances,  to  afi"ord  data 
for  a  safe  answer.  I  do  not  think,  from  what  inquiries  I  have  made,  that 
the  ages  of  parents  affect  the  production  of  deaf-dumbness. 

Families  consisting  of  from  six  to  seven  children  presented  single  mutes 
in  a  greater  number  of  instances  than  other  families.  It  is  remarkable  that, 
while  the  male  sex  largely  predominated  in  all  other  instances,  the  sexes  of 
mutes  where  equal  in  84  instances  in  which  the  eighth  child  was  born  deaf 
and  dumb. 

Fourteen  instances  of  twins  occurred,  in  which  one  or  both  were  mute,  the 
sexes  of  the  28  children  being  equal.  In  a  family  of  13,  in  the  county  of 
Sligo,  mute  twins  occurred  twice,  being  the  seventh  and  eighth  births ;  in 
the  former,  both  children  were  mute  females ;  in  the  latter,  a  male  and  fe- 
male, the  boy  not  mute.  Of  the  entire  13  births  in  that  family,  5  were 
males,  none  of  whom  presented  any  defect,  and  8  females,  of  whom  7  were 
deaf  and  dumb  ;  the  order  of  the  births  of  the  mutes  being  the  third,  fourth, 
fifth,  seventh,  eighth,  ninth,  and  eleventh.  The  parents  of  these  children 
were  related.  Where  both  children  were  of  the  same  sex,  in  3  cases  but 
one  child  was  deaf  and  dumb,  and  in  2  instances,  where  the  sexes  differed, 
only  one  child  was  deaf  and  dumb.  In  6  of  the  14  cases,  the  twins 
were  first  births;  in  3,  third  births ;  in  2,  seventh  births ;  in  1,  the  second; 
in  1,  the  fifth ;  and  in  1,  the  ninth  birth,  that  being  the  second  twin  case  in 
the  family  in  Sligo.     The  parents  were  cousins  in  four  instances;  in  1  case 


444  APPENDIX. 

an  uncle  and  three  cousins  by  the  father's  side  were  also  mutes  ;  and  in  4 
instanceSj  other  children  of  these  families  were  also  deaf  and  dumb.  In 
one  of  these  twin  cases,  the  first  and  second  children  of  the  family  were  also 
twins,  but  not  mute. 

The  transmission  of  disease  by  hereditary  taint  or  family  peculiarity, 
whether  as  a  strumous  affection  or  otherwise,  is  very  manifest  among  the  deaf 
and  dumb ;  but,  like  most  of  the  circumstances  attending  the  peculiarities 
of  that  class,  it  is  obscure  and  difiicult  to  be  accounted  for. 

Eighty-seven  persons,  50  males  and  37  females,  born  deaf  and  dumb,  were 
married ;  of  these,  45  male  and  32  female  mutes  intermarried  with  hearing 
and  speaking  persons.  From  the  marriage  of  all  these,  182  children  had 
resulted  at  the  time  of  taking  the  census,  among  whom  there  was  but  one 
case  of  muteism.  Five  instances  were  recorded  of  the  intermarriage  of 
deaf  and  dumb  persons ;  their  offspring  amounted  to  14,  of  whom  only  one 
— a  female  in  the  city  of  Dublin — was  deaf  and  dumb.  An  instance  oc- 
curred in  the  county  of  Cavan  of  a  deaf  mute,  son  to  a  man  deaf  only,  but 
whose  uncle  and  aunt  were  deaf  and  dumb.  In  the  foregoing  enumeration 
of  offspring  are  included  some  instances  of  children  who  were  under  one 
year  of  age,  and  whose  hearing  and  speaking  powers  were  consequently  un- 
known. It  is  remarkable  that  while  muteism  is  often  manifest  in  several 
members  of  a  family  derived  from  a  common  stock,  the  defect  is  seldom 
transmitted  direct  from  parents  to  children ;  thus,  according  to  the  returns 
of  the  Hartford  Institution,  United  States,  we  learn  that  in  91  instances, 
where  both  the  parents  were  deaf  and  dumb,  in  only  4  cases  were  the  chil- 
dren similarly  affected. 

There  is  an  instance  in  the  county  of  Cavan  of  the  transmission  of  the 
disease,  in  direct  descent,  for  three  generations, — the  grandfather,  the  father, 
and  four  of  the  present  family,  being  all  deaf  and  dumb.  In  the  county  of 
Limerick  was  found  a  mute  with  five  paternal  first  cousins,  and  also  a  ma- 
ternal second  and  a  third  cousin,  all  deaf  and  dumb.  In  the  case  of  a  mute 
individual  in  the  county  of  Down,  two  grand-aunts,  two  grand-uncles,  and 
two  cousins  on  the  mother's  side,  were  also  mute.  In  one,  in  the  county 
of  Leitrim,  two  grand-uncles,  and  an  uncle  and  aunt,  by  the  father's  side, 
were  mute ;  and  in  Belfast  was  found  a  mute  who  had  an  uncle  and  aunt 
on  the  father's  side,  and  an  uncle  and  aunt  on  the  mother's  side,  all  deaf 
and  dumb.  In  the  county  of  Kerry  two  mute  children  in  the  same  family 
had  a  grand-aunt,  an  aunt,  and  a  cousin  by  the  mother's  side,  also  deaf  and 
dumb ;  and  in  the  county  of  Fermanagh,  where  two  mute  children  occurred 
in  the  same  family,  their  three  grand-aunts  and  a  grand-uncle  by  the  father's 
side  had  been  deaf  and  dumb.  Uncles,  aunts,  and  cousins,  are  the  relatives 
of  existing  mutes  who  have  most  frequently  exhibited  the  same  disease. 

Among  the  cases  which  may  fairly  be  attributed  to  hereditary  taint  is  that 
of  a  man   in  the  county  of  Down,  forty  years  of  age,  the  son  of  idiotic 


DEAF-DUMBNESS.  445 

parents,  who  is  idiotic,  not  deaf,  but  became  dumb  at  six  years  of  age.  In 
one  of  the  families,  containing  five  mutes,  there  were  no  other  children,  and 
the  father  was  also  mute.  In  the  county  of  Dublin,  a  female,  born  deaf 
and  dumb,  had  a  grand-uncle  idiotic,  and  another  grand-uncle  by  the  father's 
side,  deaf  and  dumb.  One  sister  was  also  a  deaf  mute,  and  two  sisters 
dumb  only. 

In  Kilkenny,  in  a  family  of  ten,  there  were  four  mutes,  and  one  child 
partially  deaf  and  dumb,  being  the  first,  second,  third,  fourth,  and  ninth. 
The  history  and  antecedents  of  this  case  are  remarkable.  The  maternal 
grandmother  was  insane,  and  the  maternal  grand-uncles  of  weak  intellect. 
After  the  birth  of  the  second  child  the  mother  became  insane,  and  continued 
so  at  intervals  until  the  fifth  pregnancy,  when  she  was  removed  to  a  public 
asylum.  From  the  birth  of  the  sixth  to  the  pregnancy  of  the  eighth  child, 
she  remained  with  her  family,  having  lucid  intervals  of  diflferent  duration. 
During  the  eighth  pregnancy  she  was  again  removed  to  an  asylum.  The 
tenth  child  was  perfect  in  every  respect,  but  after  its  birth  the  mother  died, 
a  raging  maniac. 

In  Waterford  a  man  had  two  deaf  and  dumb  illegitimate  children  by  two 
different  females  :  all  his  legitimate  family  were  unafi'ected. 

I  have  known  several  cases  of  acquired  deafness  in  children,  some  of 
whose  brothers  and  sisters  were  born  mute,  thus  showing  the  tendency  to 
aural  or  cerebral  affections  in  the  family. 

The  foregoing  instances  are,  however,  merely  given  as  examples  out  of 
very  many  of  the  same  class  of  which  I  possess  the  particulars. 

There  is  a  very  general  impression  abroad,  that  hereditary  disease  is  trans- 
mitted with  greater  intensity  through  the  male  than  the  female  line,  but 
this  does  not  hold  good,  so  far,  at  least,  as  congenital  muteism  is  concerned. 
Of  281  instances  exhibiting  the  result  of  hereditary  predisposition,  or  family 
peculiarity  in  the  production  of  congenital  muteism,  or  in  which  persons 
born  in  families,  some  of  the  previous  members  or  collateral  branches  of 
which  were  mute,  the  disease  was  transmitted  by  the  father's  side  in  149 
cases ;  whereas  in  the  remaining  132  it  came  through  the  female  line.  In 
5  instances  the  grandfather  was  deaf  and  dumb  ;  in  3,  the  grandmother;  in 
18,  the  grand-uncles;  in  11,  the  grand-aunts;  in  3,  the  father;  in  1,  the 
mother;  in  46,  the  uncles;  in  20,  the  aunts;  and  in  176,  the  cousins,  had 
been  deaf  and  dumb.  In  some  instances  we  find  muteism  appear  simulta- 
neously in  the  cousins  and  other  collateral  branches  of  the  same  family, 
without  any  of  the  previous  members  being  affected,  the  disease  manifest- 
ing itself  owing  to  some  hitherto  unexplained  peculiarity.  When,  however, 
one  of  the  family  is  born  deaf  and  dumb,  without  hereditary  predisposition 
or  the  consanguinity  of  parents,  not  only  are  those  descended  therefrom  liable 
to  muteism,  even  with  the  intermission  of  a  generation,  but  other  members 
of  the  same  family  often  exhibit  the  disease,  and  hence  the  natural  anxiety 


446  APPENDIX. 

evinced  by  parents  upon  observing  one  of  their  children  so  afflicted.  These 
facts,  though  difficult  to  explain,  are  some  of  the  most  curious  and  impor- 
tant in  the  history  of  deaf  muteism. 

It  has  been  asserted  that  deaf  muteism  is  principally  an  infirmity  of  the 
poor,  the  result  of  their  unhealthy  dwellings,  bad  and  insufficient  food, 
impure  air,  want  of  clothing,  and  those  other  causes  which  elicit  scrofulous 
manifestations ;  but  if  this  were  the  case  we  should  find  more  mutes  in  the 
civic  than  the  rural  districts,  whereas  the  contrary  obtains.  It  has  also 
been  stated,  that  mutes  are  inferior  in  intellectual  endowment,  owing  to  im- 
perfect cerebral  development,  but,  except  in  those  cases  complicated  with 
other  congenital  or  acquired  defects,  it  will  be  found  that  the  deaf  mute — 
when  we  take  into  account  his  deprivation  of  one  of  the  chief  inlets  of 
knowledge — shows  as  great  mental  aptitude  as  other  persons  of  the  same 
class  in  society.  The  same  arrests  of  development  and  malformations  of  the 
cerebro-spinal  system  which,  when  confined  to  the  organ  of  hearing,  produce 
deafness,  give  rise,  when  they  extend  to  the  brain,  to  idiotcy,  epilepsy,  and 
paralysis.  Hence  the  large  amount  of  362  cases,  idiotic  or  paralytic,  or  1 
in  12-39  of  the  entire  4485  returned;  while  the  general  proportion  of  the 
idiotic  to*  the  population  of  Ireland  is  1  in  1460.  Many  of  the  362  specified 
above  were  also  defective  in  stature,  or  otherwise  deformed. 

^  From  similar  circumstances  we  find  a  greater  proportion  of  insane  among 
mutes  than  among  the  population  at  large,  in  which  latter  there  is  but  1 
lunatic  in  1312,  whereas  there  were,  at  the  time  of  taking  the  census,  32 
insane  deaf  and  dumb  persons,  or  about  1  in  140  of  that  class  from  all  causes. 

Even  among  the  born  deaf  mutes  hearing  is  not  altogether  deficient. 
Itard  makes  the  following  division  upon  this  subject :  first,  those  that  can 
hear  the  human  voice  as  sounds,  but  are  unable  to  distinguish  words, 
amounting  to  about  one-tenth  of  the  whole ;  secondly,  those  who  can  distin- 
guish loud  noises,  such  as  clapping  the  hands,  the  ringing  of  bells,  thunder, 
cannon  firing,  &c.,  who  amount  to  five-tenths ;  and  thirdly,  those  who  are 
completely  deaf,  numbering  about  four-tenths  of  the  whole.  The  deaf  and 
dumb  are,  however,  particularly  sensitive  to  vibration,  and  this  is  often  mis- 
taken for  hearing.  Thus,  in  the  Institution  at  Paris,  the  movements  of  the 
pupils  are  regulated  by  beat  of  drum ;  and  in  the  American  schools  bells  are 
usually  employed  to  call  the  pupils  to  school  or  dinner;  it  must,  however, 
be  remarked,  that  notice  of  their  ringing  is  given  by  those  who  are  only 
partially  deaf,  to  the  rest.  I  may  here  mention  an  interesting  physiologi- 
cal circumstance  which  I  witnessed  during  one  of  my  visits  to  the  Imperial 
Institution  for  the  deaf  and  dumb  at  Vienna,  in  1841.  The  majority  of 
the  pupils  were  always  conscious  of  the  vicinity  of  a  military  band,  though 
at  some  distance  off;  several  of  them  were  sensibly  affected  by  diffiarent 
musical  instruments  when  played  in  the  same  room  with  them,  though 
the  performers  were  placed  behind  a  screen ;  thus  they  expressed  difi'erent 


DEAF-DUMBNESS.  447 

sensations  when  wind  or  stringed  instruments  were  played ;  and  one  boy  in 
particular  became  sick  in  his  stomach  upon  the  trombone  being  sounded 
near  him.* 

Independent,  however,  of  these  susceptibilities  to  vibration,  I  have  met 
several  cases  of  partial  congenital  deaf  muteism,  in  which  there  was  much 
imperfection  of  hearing,  and  also  a  difficulty  of  speaking  plain. 

Among  the  complications  of  muteism  may  be  mentioned,  in  addition  to 
those  already  referred  to,  bodily  deformity  and  blindness ;  in  the  former 
class  may  be  included  cases  of  curvature  of  the  spine,  extreme  decrepitude, 
hare-lip,  malformations  of  the  head,  and  partial  deficiency  of  some  of  the 
extremities,  &c. 

It  has  been  discussed  whether  blindness  or  deafness  is  the  greater  pri- 
vation; and  it  is  asserted  that  in  after-life  the  loss  of  sight  is  a  greater 
privation  than  that  of  hearing ;  but  with  this  I  do  not  agree,  for  we  know 
that  the  memory  of  objects  affords  greater  consolation  to  the  blind  than  the 
memory  of  sounds  does  to  the  totally  deaf.  In  a  spiritual  point  of  view, 
congenital  deafness  is  the  greater  affliction,  for  the  child  so  born  remains 
shut  up  within  himself,  and,  without  great  educational  efforts,  his  under- 
standing must  for  ever  remain  undeveloped,  hearing  being  the  chief  instru- 
ment for  psychological  advance,  while  sight  is  only  necessary  for  physical 
objects.  The  blind,  however,  as  has  been  well  remarked  by  Dr.  Frank, 
meet  with  more  sympathy  from  society,  probably  because  deafness  is  not 
accompanied  by.  any  apparent  physical  defect.  But  when  the  person,  either 
from  congenital  malformation  or  acquired  disease,  is  deprived  both  of  the 
senses  of  hearing  and  seeing,  great,  indeed,  must  be  his  affliction. 

The  earliest  record  of  a  person  deprived  of  the  threefold  faculty  of  hear- 
ing, speaking,  and  seeing,  is  that  afforded  by  St.  Matthew  (chapter  xii.  ver. 
22).  De  I'Epee,  and  subsequently  Sicard,  endeavored  to  ascertain  if  an 
individual  so  circumstanced  could  be  found,  in  order  that  they  might  test 
the  value  of  the  systems  of  instruction  which  they  advocated ;  but  no  such 
instance  presented  during  their  time.  At  the  commencement  of  the  pre- 
sent century,  however,  much  attention  was  attracted  to  an  instance  of  this 
triple  calamity  in  the  person  of  James  Mitchell,  a  boy  from  the  Highlands 
of  Scotland,  who  labored  under  congenital  deafness  and  blindness,  the  latter 
caused  by  cataract.  When  about  thirteen  years  of  age,  he  was  brought  to 
London,  when  Mr.  Saunders  couched  the  cataract  on  the  left  side,  from 
which  operation  he  gained  temporary  vision ;  and  Sir  Astley  Cooper  also 
performed  upon  him  the  then  fashionable  operation  of  perforation  of  the 
membrana  tympani.  Subsequently  Mr.  Wardrop  succeeded  in  displacing 
the  opaque  lens,  and  for  a  time  he  gained  a  fair  share  of  vision,  but  eventu- 
ally he  was  barely  able  to  find  his  way.     Dugald  Stewart  wrote  an  essay, 

1  See  the  Author's  "  Austria,  its  Literary,  Scientific,  and  Medical  Institutions,"  &c. 


448  APPENDIX. 

in  connexion  with  his  Philosophy  of  the  Human  Mind,  upon  the  case  of 
James  Mitchell,  in  which  is  embodied  Mr.  Wardrop's  account  of  the  opera- 
tion, as  well  as  an  account  of  the  boy's  state  when  he  first  visited  London. 
Mr.  Wardrop  also  wrote  the  "  History  of  James  Mitchell,  a  boy  blind  and 
deaf,  with  an  account  of  the  operation  for  the  recovery  of  his  sight :"  1813. 
Dr.  Grordon,  his  usual  medical  attendant,  wrote  a  paper  concerning  Mitchell 
in  the  third  volume  of  the  Transactions  of  the  Royal  Society  of  Edinburgh; 
and  Dr.  Spurzheim  has  given  an  interesting  account  of  him  in  his  Phrenology. 

The  Gentleman's  Magazine  for  the  year  1808  records  the  death,  by  burn- 
ing, of  Hannah  Lamb,  a  girl  nine  years  of  age,  who  was  born  deaf,  dumb, 
and  blind,  but  without  giving  any  further  history  of  her  case. 

The  Abbe  Carton  received  into  the  Institution  at  Bruges  a  deaf,  dumb, 
and  blind  girl,  named  Anna  Temmermans,  some  years  ago,  and  had  com- 
menced her  education  with  great  zeal,  but  as  yet  we  have  not  learned  with 
what  result. 

The  earliest  case  recorded  in  America  is  that  of  Julia  Brace,  who  is,  I 
believe,  still  living  in  Hartford  Asylum.  The  most  recent  account  of  her 
state  is  that  given  by  Mr.  Woodroff  in  the  American  Annals  for  January, 
1849 ;  bul!  little  advance  had  then  been  made  with  her  education,  and,  as 
she  was  aged  35  years,  it  is  not  likely  that  much  will  be  effected.  The  Re- 
port, however,  states  that  she  was  intelligent,  and  could  hold  communica- 
tion by  natural  signs.  The  case  of  Laura  Bridgman,  the  pupil  of  the 
benevolent  and  indefatigable  Dr.  Howe,  has  enjoyed  a  world-wide  celebrity. 
This  interesting  young  woman,  deaf,  dumb,  and  blind,  and  also  deprived  of 
the  sense  of  smell,  and  with  imperfect  taste,  was  born  at  Hanover,  New 
Hampshire,  in  1829.  It  does  not  appear  that  she  was  congenitally  deaf; 
and  the  account  states  that  she  had,  when  an  infant,  bright  blue  eyes,  and 
also  displayed  a  considerable  degree  of  intelligence.  During  her  second 
and  third  years  she  suffered  from  convulsions,  and  had  a  violent  fever  of 
several  weeks'  duration,  when  her  eyes  and  ears  inflamed,  suppurated,  and 
their  contents  were  discharged;  it  was  also  found,  upon  her  recovery,  that 
the  other  two  senses  of  smell  and  taste  were  greatly  impaired,  and  it  was 
only  at  the  age  of  four  years  that  the  child's  health  was  so  much  restored 
as  to  enable  her  to  walk  unsupported.  Dr.  Howe,  director  of  the  Perkins 
Institution  for  the  Blind,  at  Boston,  having  heard  of  her,  immediately 
hastened  to  Hanover,  when  he  says,  "  I  found  her  with  a  well-formed  figure, 
a  strongly  marked  nervous-sanguine  temperament,  a  large  and  beautifully 
shaped  head,  and  the  whole  system  in  healthy  action."  She  was  then 
little  more  than  seven  years  of  age,  and  the  moral  effects  of  her  privation 
had  already  begun  to  appear.  She  was  received  into  the  Boston  Asylum 
in  October,  1837.  Fortunately  for  the  education  and  consequent  happi- 
ness of  this  child,  the  raised-letter  alphabet  had  been  invented,  and  with  its 
use  and  the  value  of  the  different  characters,  she  after  some  time  became 


DEAF-DUMBNESS.  449 

acquainted, — the  large,  raised  letters  being  attached  in  labels  to  the  diffe- 
rent articles  with  -which  she  was  made  familiar.  After  a  while,  instead  of 
labels,  the  individual  letters  were  given  to  her,  and  she  was  taught  to  place 
them  so  as  to  spell  the  name  of  the  article  presented.  "  Hitherto,"  says 
Dr.  Howe,  in  his  first  report  upon  Laura  Bridgman,  in  1841,  "  the  process 
had  been  mechanical,  and  the  success  about  as  great  as  teaching  a  very- 
knowing  dog  a  variety  of  tricks.  The  poor  child  had  sat  in  mute  amaze- 
ment, and  patiently  imitated  everything  her  teacher  did;  but  now  the  truth 
began  to  flash  upon  her — her  intellect  began  to  work — she  perceived  that 
here  was  a  way  by  which  she  could  herself  make  up  a  sign  of  anything  that 
was  in  her  own  mind,  and  to  show  it  to  another  mind,  and  at  once  her 
countenance  lighted  up  with  a  human  expression ;  it  was  no  longer  a  dog,  or 
parrot, — it  was  an  immortal  spirit,  eagerly  seizing  upon  a  new  link  of  union 
with  other  spirits  !  I  could  almost  fix  upon  the  moment  when  this  truth 
dawned  upon  her  mind,  and  spread  its  light  to  her  countenance  :  I  saw  that 
the  great  obstacle  was  overcome,  and  that  henceforward  nothing  but  patient 
and  persevering,  but  plain  and  straightforward,  efforts  were  to  be  used. 

"  She  was  exercised  for  several  weeks  in  this  way,  until  her  vocabulary 
became  extensive;  and  then  the  important  step  was  taken  of  teaching  her 
how  to  represent  the  different  letters  by  the  position  of  her  fingers,  instead 
of  the  cumbrous  apparatus  of  the  board  and  types.  She  accomplished  this 
speedily  and  easily,  for  her  intellect  had  begun  to  work  in  aid  of  her 
teacher,    and  her  progress  was  rapid. 

"  This  was  the  period,  about  three  months  after  she  had  commenced,  that 
the  first  report  of  her  case  was  made,  in  which  it  is  stated  that  '  she  had 
just  learned  the  manual  alphabet,  as  used  by  the  deaf  mutes;  and  it  is  a 
subject  of  delight  and  wonder  to  see  how  rapidly,  correctly,  and  eagerly, 
she  goes  on  with  her  labors.  Her  teacher  gives  her  a  new  object, — for 
instance,  a  pencil,  first  lets  her  examine  it,  and  get  an  idea  of  its  use,  then 
teaches  her  how  to  spell  it  by  making  the  signs  for  the  letters  with  her  own 
fingers ;  the  child  grasps  her  hand,  and  feels  of  her  fingers,  as  the  different 
letters  are  formed ;  she  turns  her  head  a  little  one  side,  like  a  person  listen- 
ing closely — her  lips  are  apart — she  seems  scarcely  to  breathe,  and  her 
countenance,  at  first  anxious,  gradually  changes  to  a  smile,  as  she  compre- 
hends the  lesson.  She  then  holds  up  her  tiny  fingers,  and  spells  the  word 
in  the  manual  alphabet ;  next,  she  takes  her  types,  and  arranges  her  letters ; 
and  last,  to  make  sure  that  she  is  right,  she  takes  the  whole  of  the  types 
composing  the  word,  and  places  them  upon  or  in  contact  with  the  pencil, 
or  whatever  the  object  may  be.'  " 

With  the  subsequent  progress  of  this  interesting  creature, — who  is,  un- 
doubtedly, the  best  taught  blind  mute  ever  heard  of,  the  world  is  already 
well  acquainted.  I  have  introduced  the  foregoing  extracts,  in  order  to 
point  out  the  steps  adopted  at  the  commencement  of  her  instruction,  in  the 

29 


450  APPENDIX. 

hope  of  directing  those  who  may  meet  similar  instances  to  make  some  effort 
for  their  alleviation  j  and  for  further  information  I  beg  to  direct  the  reader's 
attention  to  "  The  Reports  of  the  Perkins  Institution  and  Massachusetts 
Asylum  for  the  Blind,"  from  1841  to  the  present  time. 

Three  other  cases  have  occurred  in  America,  of  which  notices  have  been 
recorded,  but  none  of  them  have  attained  the  same  perfection  in  acquiring 
knowledge  as  Laura  Bridgman,  who  seems  to  be  a  person  of  unusual  mental 
endowments.  None  of  the  American  cases  appear  to  have  been  born  either 
deaf  or  blind,  but  each  had  lost  the  sense  of  sight  and  hearing  during  the 
first  few  years  of  life. 

The  reports  of  the  Glasgow  Society  for  the  Education  of  the  Deaf  and 
Dumb  contain  much  valuable  information.  In  that  for  1839,  it  is  stated 
that  in  the  mountainous  island  of  Arran,  at  the  mouth  of  the  Clyde,  there 
were  no  fewer  than  twelve  mutes,  in  a  population  of  6427.  The  same 
report  likewise  contains  "  Memoirs  of  persons  born  deaf,  dumb,  and  blind," 
embracing,  in  addition  to  some  of  those  specified  in  the  foregoing  pages,  the 
instances  of — David  Gilbert  Tate  ;  of  an  English  lady,  whose  case  is  de- 
scribed by  our  countryman.  Sir  Hans  Sloane ;  of  Mdlle.  Morisseau,  a  con- 
genital deaf  mute,  who  became  blind  in  the  Parisian  Institution,  at  the  age 
of  13  ;  and  of  Mary  M'Leod.  Tate  was  discovered  by  Dr.  Herbert  in  the 
island  of  Fetlar,  one  of  the  Shetland  group,  in  1818  :  "  His  parents  occu- 
pied a  miserable  hovel,  in  wretched  poverty,  and  had  so  neglected  this 
child, — deeming  his  condition  beyond  the  possibility  of  melioration, — that 
he  was  not  even  able  to  walk  erect."  The  account  of  the  English  lady, 
who  was  at  mature  age  deprived  of  sight,  hearing,  and  speech,  will  be 
found  in  the  Annual  Register  for  1758.  Mary  M'Leod  "was  born  blind 
at  Portobello,  near  Edinburgh,  in  1824,  and  at  the  age  of  three  years 
lost  her  speech.  Like  Tate,  she  moved  about  her  apartment  on  her  hands 
and  feet,  and  her  habits  became  extremely  disgusting.  When  she  had 
taken  food,  she  became  furious  if  not  allowed  to  destroy  the  vessel  which 
contained  it."  This  girl,  like  Hannah  Lamb,  already  alluded  to  at  page 
448,  was  burned  to  death. 

No  doubt  many  cases  of  muteism  with  blindness  must  have  occurred 
upon  the  Continent,  and  perhaps  several  at  present  exist  there,  but  I  have 
not  met  with  notices  of  them  in  any  French  or  German  work.  Mr.  I.  L. 
Peet  has  given  an  account  (in  the  Proceedings  of  the  Second  Convention  of 
American  Instructors,  already  alluded  to  at  p.  430),  of  a  young  man,  named 
Edward  Meystre,  whom  he  had  seen  in  the  Institution  for  the  Blind,  at 
Lausanne,  under  the  care  of  Mr.  Hirzel,  its  talented  Director.  Meystre, 
who,  if  living,  is  now  aged  about  27,  lost  his  hearing  from  small-pox  when 
eleven  months  old ;  and  when  eight  years  of  age  was  completely  deprived 
of  sight  by  the  accidental  discharge  of  a  gun,  loaded  with  small  shot.  In  a 
tract  on  this  subject  quoted  by  Mr.  Peet,  Mr.  Hirzel  says, — "  the  character 


DEAF-DUMBNESS.  451 

of  the  deaf  mute  decidedly  predominates  ia  this  young  man ;  we  might  even 
say  that  it  masters  blindness.  All  his  movements  are  free  and  decided, 
whilst  those  of  the  blind  are  in  general  embarrassed  and  uncertain.  He 
retains  not  the  least  gleaming  of  light,  and  his  auditive  perception  is  en- 
tirely wanting  in  the  right  ear ;  with  the  left  he  is  able  vaguely  to  distin- 
guish a  very  loud  noise,  or  a  very  sharp  sound.  I  have,  however,  made 
the  experiment  several  times  of  discharging  percussion  caps,  at  two  paces 
distance,  but  in  the  open  air,  without  his  perceiving  it  at  all.  His  touch 
is  sure ;  but,  blunted  by  an  employment  which  hardens  the  skin,  it  has  not 
the  delicacy  which  we  observe  in  most  of  the  blind.  His  sense  of  smell, 
though  sufficiently  acute,  offers  nothing  worthy  of  remark." 

The  account  given  of  the  system  of  instruction  pursued  in  this  case  is 
most  interesting.  After  the  pupil  had  made  considerable  progress  in  the 
usual  means  already  detailed  in  Laura  Bridgman's  case,  an  attempt  was 
made  to  see  if  it  were  possible  to  give  him  speech  to  a  certain  extent : 
'' Placing  one  of  Meystre's  hands  on  my  chest,"  writes  Mr.  Hirzel,  "  I  blew 
against  the  other,  and  then  made  him  feel  my  throat  while  I  pronounced 
the  vowel  «,  directing  him  also  to  exhale  a  current  of  air  from  his  lungs,  to 
cause  the  larynx  to  vibrate.  In  this  way  I  obtained  the  first  vowel.  Then 
a  new  difficulty  presented  itself;  the  pupil  opposed  my  endeavors,  saying 
that  those  who  could  neither  see  nor  hear  were  incapable  of  speech,  and 
that  these  efforts  fatigued  him.  In  this  emergency  I  had  recourse  to  his 
sensual  appetite,  and  the  plan  succeeded.  Knowing  his  fondness  for  cigars, 
I  promised  them  to  him  at  discretion,  if  he  would  continue  to  be  docile,  and 
he  willingly  submitted  to  exercises  which  were  the  more  difficult  as  he  could 
see  no  utility  in  them.  When,  after  repeated  endeavors,  I  had  succeeded  in 
bringing  his  vocal  organs  to  their  proper  position,  he  became  able  to  pro- 
nounce with  sufficient  distinctness  the  vowels  a  and  o.  But  in  proceeding 
further,  I  met  with  obstacles  which  at  first  appeared  insurmountable ;  for 
during  fifteen  days  every  attempt  to  distinguish  the  sound  ai  from  that  of 
a  or  of  0,  &c.,  failed,  and  I  began  to  fear  that  it  was  only  time  lost.  In- 
wardly convinced,  however,  of  the  existence  of  a  law  which,  in  the  appren- 
ticeship of  speech,  should  supply  to  the  touch  what  the  movement  of  the 
lips  was  to  the  eye,  I  made  a  last  effort,  in  the  hope  of  discovering  it.  At 
last,  when  on  the  point  of  being  discouraged,  the  reflection  of  what  perse- 
verance could  accomplish  reanimated  me,  and  I  found  that  which  I  sought. 
This  law  being  observed,  the  deaf  mute  immediately  pronounced  four 
vowels." 

This  is,  I  believe,  the  first  instance  in  which  a  person  deaf,  dumb,  and 
blind,  has  been  taught  to  speak.  Of  the  success  which  attended  the  bene- 
volent efforts  of  the  instructor  we  may  judge  by  the  account  given  by  Mr. 
Mr.  Peet  of  his  first  introduction  to  Meystre,  who  was  informed  by  his 
teacher,  by  means  of  the  manual  alphabet,  that  Mr.  Peet  had  come  from 


452  APPENDIX. 

America,  and  that  three  of  his  company  were,  like  Meystre  himself,  deaf 
and  dumb.  "  What  was  our  surprise  when  this  blind,  deaf  mute  repeated, 
in  quite  a  distinct  tone  of  voice,  what  his  teacher  had  told  him,  and  then 
with  a  little  apparatus  prepared  for  the  purpose,  stamped  it  on  paper  !  As 
his  teacher  communicated  it  to  him,  he  turned  to  us  with  a  smile  of  plea- 
sure, and  welcomed  us,  saying  by  signs  that  he  understood.  At  the  word 
America,  he  pointed  to  his  teacher,  and  made  signs  for  sailing  over  the 
waves.  We  were  also  quite  gratified  in  looking  over  some  of  his  indepen- 
dent compositions.  We  afterwards  saw  him  in  the  workshop,  at  his  turning 
lathe,  chiselling  with  remarkable  skill  and  exactness.  A  number  of  articles 
made  by  him,  beautifully  executed,  were  exhibited  in  a  case ;  they  would 
have  been  creditable  to  any  workman." 

We  had  in  Ireland  some  years  ago  a  very  notable  case  of  a  deaf,  dumb, 
and  blind  girl,  whom  I  have  frequently  seen  and  examined ;  she  was  a  con- 
genital mute,  and  had  lost  her  sight  in  infancy,  from  purulent  ophthalmia. 
She  was  well  formed,  and  remarkably  intelligent;  her  intelligence,  however, 
was  converted  into  cunning  by  the  training  and  artifices  of  an  exceedingly 
clever  mother,  who  made  a  livelihood  by  showing  her  as  a  monster,  and 
who  resisted  every  means  taken  by  many  benevolent  persons  to  provide  an 
asylum  and  suitable  instruction  for  her  child.  The  girl  had  rather  a  placid 
expression  of  countenance,  exceedingly  delicate  hands,  and — like  all  simi- 
larly circumstanced  persons — an  exquisitely  delicate  sense  of  touch,  so  that 
she  could  tell  any  portion  of  her  mother's  dress  by  feeling  it,  even  when 
held  by  another.  She  was  fond  of  sewing,  which  she  could  execute  with 
great  neatness ;  but  the  most  remarkable  feat  which  she  performed  was 
that  of  threading  her  needle,  and  this  she  eiFected  in  the  following  manner 
with  her  tongue  : — Having  discovered  on  which  side  the  eye  was  placed,  she 
then  fixed  the  needle  between  two  of  her  lower  teeth,  a  little  to  one  side, 
and,  having  pointed  the  thread  in  the  usual  manner,  she  laid  it  upon  the 
tip  of  her  tongue,  with  one  or  two  lateral  motions  of  which  she  managed  to 
pass  it  through  the  needle.  With  such  adroitness  and  rapidity  was  this 
effected,  that  it  was  scarcely  possible  to  observe  the  process.  She  knew 
the  value  of  different  coins,  and  expressed  her  gratitude  for  receiving  money 
by  kissing  the  hand  of  her  benefactor.  She  could  communicate  with  her 
mother  by  a  number  of  natural  and  arbitrary  signs,  and  was  exceedingly 
apt  at  receiving  any  instruction  that  was  afforded  her.  She  occasionally 
suffered  much  annoyance  from  her  eyes,  as  the  surfaces  both  of  the  globes 
and  the  interior  of  the  lids  were  a  mass  of  fungous  granulations.  For 
several  years  tkis  poor  child  was  exposed  by  her  heartless  parent,  during 
the  most  inclement  weather,  by  the  wayside,  in  some  of  the  outskirts  of 
Dublin ;  there  she  might  be  seen  sitting  for  hours,  with  a  placard  attached 
to  her  breast  setting  forth  her  infirmities,  and  receiving  the  occasional  alms 
of  the  passer-by, — while  the  mother  generally  lingered  at  some  distance, 


DEAF-DUMBXESS.  453 

watching  the  result,  but  never  approaching  her  when  any  person  was  in  sight. 
When  last  I  saw  her,  she  and  her  mother  were  inmates  of  the  South  Dublin 
Union  Workhouse,  where  the  poor  girl  died  in  1847.  This  is  the  case 
alluded  to  by  Dr.  Howe,  in  the  Appendix  to  the  Ninth  Report  of  the  Mas- 
sachusetts Asylum,  in  1841.  At  that  time  arrangements  were  being  made 
at  Belfast  to  have  her  instructed,  but  before  they  were  completed,  the 
mother  absconded  with  the  little  girl. 

During  our  investigations  under  the  last  Census  Commission,  we  disco- 
vered sis  deaf,  dumb,  and  blind  persons  in  Ireland,  and  four  of  these  were 
likewise  paralytic,  idiotic,  or  deformed.  Among  the  latter,  a  female,  then 
aged  four  years,  was  deaf  and  dumb,  unable  to  walk,  idiotic,  had  hare-lip 
and  cleft  palate,  and  was  also  blind  of  both  eyes,  one  from  amaurosis;  the 
other  from  cataract.  Another  of  the  idiotic  deaf  and  dumb  had  congenital 
cataract. 

The  two  cases  of  most  interest  are  those  of  Daniel  Cole,  in  the  city  of 
Dublin,  and  Hugh  Gorman,  in  the  county  of  Tyrone.  The  former  is  a  boy 
aged  ten,  the  seventh  of  eight  children,  and  who  was  born  deaf,  dumb,  and 
blind.  The  mother  attributes  the  defect  in  her  child  to  a  fright  she  received 
during  pregnancy.  This  boy,  whom  I  have  had  many  opportunities  of 
examining,  is  delicately  formed,  rather  small  for  his  age,  and  had  an  attack 
of  hydrocephalus  in  infancy.  The  head  is  natural,  but  the  face  and  general 
appearance  convey  at  first  sight  an  appearance  of  idiotcy — the  eyes  being 
very  large,  egg-shaped,  turned  permanently  downwards,  and  completely 
covered  by  the  thinned  eyelids.  On  the  right  side  the  cornea  is  natural, 
and  the  humors  transparent,  but  the  organ  is  totally  insensible  to  light. 
The  left  eye  suffered  from  inflammation  some  years  ago,  and  the  cornea  is 
now  quite  opaque.  He  got  his  infantile  teeth  at  the  usual  period,  but  the 
mother  says  they  rotted  away  shortly  after  the  attack  of  water  on  the  brain. 
The  mouth  is  now  totally  devoid  of  teeth,  and  the  tongue  is  nearly  double 
the  natural  size,  hangs  out  of  the  mouth  for  about  half  its  length,  is  very 
deeply  fissured  over  its  entire  surface,  and  presents  a  dry,  toasted  appear- 
ance, like  that  of  a  patient  laboring  under  typhus  fever ;  it  is  incapable  of 
being  retracted,  and  the  mother  says  it  has  remained  in  this  state  since 
birth.  He  seems  of  a  gentle  disposition,  is  by  no  means  devoid  of  intellect, 
and  is  in  all  other  respects  healthy.  He  has  already  acquired  certain  signs 
by  which  to  express  his  peculiar  wants ;  and  his  mother,  who  is  a  person 
of  intelligence,  and  exhibits  much  affection  for  her  child,  has  taught  him 
several  letters  of  the  manual  alphabet  by  making  him  feel  her  fingers.  He 
can  thus  figure  the  letters  upon  his  fingers,  forming  "  bread,"  and  several 
other  words.  His  sense  of  touch  seems  particularly  acute,  and  he  feels 
with  great  care  every  substance  with  which  he  comes  in  contact,  and  espe- 
cially the  dresses  of  the  persons  around  him.  He  is  conscious  of  the  fire, 
and  in  moving  about  the  room  carefully  avoids  it,  keeping  at  a  particular 


454  APPENDIX. 

distance,  and  walking  up  and  down  before  it  when  lie  wishes  to  warm  him- 
self. It  is  much  to  be  regretted  that  this  poor  child's  education  has  not 
received  the  attention  which  it  deserves. 

The  case  in  the  county  of  Tyrone  is  a  male,  now  aged  six,  the  first  of  two 
children,  and  was  born  deaf,  dumb,  and  blind.  The  cause  assigned  is  pre- 
mature birth ;  none  of  the  previous  family  were  affected.  The  following 
report  of  this  child  was  received  from  Dr.  Twigg : — "  He  is  well-formed, 
healthy,  handsome,  and,  considering  his  peculiar  circumstances,  intelligent. 
The  only  thing  against  his  appearance  is  a  strabismus  of  both  eyes.  He  is 
quite  blind,  but  has  not  cataract,  and  the  pupils  are  perfectly  sensible  to 
light.  He  smells  his  food  before  he  eats  it,  and  also  everything  he  touches 
that  he  is  not  previously  acquainted  with.  His  sense  of  touch  appears  par- 
ticularly acute ;  he  rubs  everything  he  touches  between  the  palms  of  his 
hands.  There  were  some  clothes  drying  in  the  house  when  I  visited  him ; 
when  he  came  in  contact  with  these  he  smelt  them,  and  then  rubbed  them 
gently  between  his  hands.  His  mother  placed  him  near  the  fire,  and  he 
cautiously  passed  from  one  side  to  the  other,  keeping  at  an  equal  distance 
all  the  way.  He  likes  to  have  a  switch  in  his  hand,  with  which  he  beats 
gently  upon  his  head.  His  mother  says,  that  when  irritated,  he  beats  his 
head  with  the  stick,  or  any  instrument  he  can  find.  He  makes  his  wants 
known  by  crying."  This  seems  an  instance  of  uncomplicated  blindness 
and  muteism,  which  may  hereafter  be  susceptible  of  education.  It  is  curious 
that  the  same  peculiarity  of  beating  upon  the  head  with  some  solid  sub- 
stance existed  in  James  Mitchell's  case,  related  at  page  447. 

There  are  in  most  countries  more  persons  totally  deprived  of  sight  than 
of  hearing.  The  average  blind  is  about  one  in  a  thousand,  but  this  varies 
in  different  localities,  and  apparently  owing  to  cei"tain  physical  causes,  usually 
the  reverse  of  those  which  induce  muteism.  Thus  in  elevated  regions,  as 
in  Switzerland  and  Sardinia,  where  deaf-dumbness  is  so  prevalent  that  the 
proportion  of  mutes  to  the  population  is  about  1  in  500,  there  is  only  1 
blind  person  in  every  1500  inhabitants.  The  casualities  affecting  the 
organs  of  sight  are  many  more  than  those  affecting  the  organs  of  hearing. 
As  yet  the  records  of  instances  of  this  triple  calamity  are  not  sufficiently 
numerous  nor  exact  to  enable  statisticians  to  say  in  what  proportion  it 
occurs.  Congenital  cataract  is  not  quite  so  rare  a  disease  as  most  persons 
suppose.  It  is  decidedly  hereditary,  and  frequently  occurs  in  several  mem- 
bers of  the  same  family.  If  it  happens  as  frequently  as  once  in  10,000,  it 
is  the  most.  Congenital  amaurosis  is  a  still  less  frequent  affection ;  and 
atrophy,  or  enlargement  of  the  globe,  are  still  rarer  forms  of  born  disease.^ 
Moreovei',  in  congenital  cataract,  unless  when  complicated  with  amaurosis 

'  Upon  this  subject  see  the  author's  essay  on  Congenital  Malformations  and  Diseases 
of  the  Organs  of  Sight,  in  the  Dublin  Medical  Journal. 


DEAF-DUMBNESS.  455 

or  hydrocephalus,  there  is  in  the  majority  of  instances  only  impaired  vision, 
not  total  loss  of  sight,  so  that  upon  the  whole,  persons  born  totally  blind 
are  comparatively  very  scarce.  The  combination  of  both  congenital  deaf- 
ness and  blindness  must  consequently  be  an  exceedingly  rare  affection,  occur- 
ring, perhaps,  about  once  in  a  million.  An  analysis  of  the  history  and 
pathology  of  the  various  cases  which  have  been  published  confirm  these  re- 
marks,— one  or  other  of  the  defects,  and  sometimes  both,  being  the  result 
of  disease  or  accident  acquired  after  birth. 

Having  thus  far  considered  the  subject  of  congenital  deaf-dumbness,  and 
in  the  preceding  remarks  shown  what  circumstances  seem  to  conduce  to 
its  propagation  and  maintenance,  as  well  as  the  laws  by  which  it  would 
appear  to  be  regulated,  we  now  come  to  inquire  into  the  causes  of  muteism 
acquired  after  birth. 

The  reports  of  some  of  the  institutions  for  the  deaf  and  dumb  contain 
tables  showing  the  causes  of  acquired  deafness.  Until  lately,  the  most 
extensive  table  of  this  kind  was  that  published  in  the  Eighteenth  Annual 
Report  of  the  New  York  Institution,  for  1837,  compounded  of  the  statistics 
of  several  of  the  European  institutions,  as  well  as  those  of  America,  and 
enumerating  in  all  787  instances.  The  Prussian  investigations  have,  like 
most  other  inquiries  in  that  admirably  managed  country,  taken  into  account 
this  and  every  other  subject  connected  with  deaf  muteism,  and  the  results 
which  have  been  published  from  time  to  time  are  most  valuable.  One  of 
the  most  voluminous  tables,  showing  the  causes  of  acquired  deaf-dumbness, 
is  that  in  the  work  issued  by  the  Belgian  Grovernment,  alluded  to  at  page 
432.  We  find  there  the  causes  of  acquired  deafness  in  402  cases  in  Bel- 
gium; 80  in  Modena;  201  in  Holland;  422  from  the  Hartford  Institution, 
U.  S.,  and  787  from  different  other  countries;  in  all  amounting  to  1892. 
But  in  some  of  the  columns  of  that  table  the  sexes  are  not  given,  and  as 
yet  I  have  not  met  with  any  table  showing  the  ages  at  which  the  particular 
diseases  which  induced  deafness  occurred.  M.  Pendola,  .who  published,  in 
1843,  a  table  exhibiting  the  amount  and  causes  of  deaf  muteism  in  697 
cases  in  the  Duchy  of  Tuscany,  made  the  following  division  : — Congenital 
or  of  unknown  origin,  432 ;  affections  of  the  gastro-intestinal  system,  69  ; 
of  the  cerebro-spinal,  91;  of  the  glandular  and  lymphatic,  81;  from  trau- 
matic causes,  22;  and  from  anomalies  in  the  organs  of  hearing,  2. 

The  table  upon  the  following  page,  extracted  from  the  report  which  I 
laid  before  the  statistical  section  of  the  British  Association  in  1852,  and 
compiled  from  the  Irish  Census  of  1851,  combines  both  the  causes  of  deaf- 
ness, the  sexes  affected,  and  the  ages  at  which  the  different  diseases  or  acci- 
dents occurred  which  induced  muteism.  This  is,  I  believe,  the  only  table 
of  the  kind  which  has  yet  been  published.  I  have,  in  it,  for  the  sake  of 
classification,  divided  the  diseases  or  accidents  which  produced  deafness, 
and  subsequent  loss  of  speech  into  three  sections.     The  first  includes  those 


456 


APPENDIX. 


diseases  which,  although  chiefly  of  an  epidemic  character,  generally  dis- 
organize the  mechanical  portion  of  the  apparatus  of  hearing,  by  inducing 
local  affections,  consequent  on  the  original  malady.  Of  these,  small-pox, 
measles,  scarlatina,  and  influenza,  produced  complete  deafness  in  fifty-seven 
instances,  by  exciting  local  inflammation,  ending  in  suppuration  in  the 
middle  and  internal  ear.  Scarlatina  is,  as  I  have  so  frequently  remarked  in 
the  previous  portions  of  this  work,  one  of  the  most  common  causes  of  sup- 
puration of  the  cavity  of  the  tympanum,  ending  in  destruction  of  the  mem- 
brana  tympani,  and  the  evacuation  of  the  ossicula.     According  to  the  Irish 


CAUSES. 

AGES   AT   WHICH   DISEASE   OR   ACCIDENT   OCCURRED. 

TOTAL. 

Under 
3yrs. 

3. 

4. 

5. 

6. 

7. 

8. 

9. 

10. 

10  to 
15. 

Above 
15. 

"3 

"a 

e 

5 
0 

M. 

f.  m. 

F. 

M. 

f. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

r. 

M. 

F. 

M. 

F. 

M. 

F. 

M. 

F. 

Affections  acting  locally 
ON  THE  Organs  of  Hear- 
ing. 

Scarlatina,  * 

Small-pox, 

Disease  of  Ears,     .... 

Measles, 

Disease  of  Throat,  .... 

Influenza 

Disease  of  Mouth,    .... 
Injury  of  Ears, 

Total, 

Diseases      and     Accidents 

AFFECTING  THE  BrAIN  AND 

Nervous  System. 

Fevers, 

Paralysis, 

Fright, 

Convulsions, 

Teething, 

Water  on  the  Brain,    .    .    . 
Epilepsy,     ....... 

Sudden    Immersion    in 

Water, 

Effects  of  Burns,    .... 

Hooping-cough 

Disease  of  the  I3rain,  .  .  . 
Paralysis  of  Tongue, .  .  . 
"  Suddenly  struck,"  .  .  . 
Attributed   to  superstitious 

causes, 

Injuries  of  Head,     .... 

Total, 

Unclassified. 

Effects  of  Cold  and  Expo- 
sure,      

Dysentery, 

Scrofula, 

Childbirth, 

Injuries  unspecified,    .    .    . 
Cause  unspecified, .... 

General  Total,     .    .    . 

4 

3 

10 
3 
9 

2 
2 
1 
1 

'4" 
35 

7 

"3 
16 

65 

3 
2 

1 
2 

1 

3 
"2 

4 
1 

'3 
1 

1 

5 
'2 

7 

4 
3 
6 
1 

'2 
2 

'2 

1 
19 

2 

io 
39 

2 

i 

i 

7 

6 
4 
2 

1 

i 

1 

15 

1 

4 
10 

37 

1 

i 

i 
1 

4 

4 

1 

i 

1 
2 

9 

2 

6 
21 

2 

"i 

3 

s 

2 

3 

10 
2 

i 

17 

3 

i 

4 

4 
2 

i 

i 

i 
9 

2 
"2 

15 

1 

1 

'2 

4 

5 
3 

1 

9 

1 

5 
19 

2 
1 

'i 

"i 

1 
1 
1 

2 

i 

"i 

7 

1 
3 

11 

1 
1 

1 

"i 

"i 

1 

1 

i 
3 

1 

1 

2 

1 
1 

2 
1 

i 
2 

8 

"i 
1 

1 

1 
1 

2 

3 
3 

2 

1 

'2 
11 

4 

4 
21 

18 

2 
8 

33 

33 
30 
16 

16 

"e 
3 

4 
3 
3 
5 

"  i 

2 

14 
136 

20 
3 

16' 
61 

263 

17 
10 
2 
6 
3 
2 
2 
1 

43 

33 
33 
17 
15 
1 
2 
4 

3 
3 
2 

2' 
1 
1 

'ib 

127 
12 

"i 

1 

8 
48 

240 

35 
12 
10 

7 
4 
3 
3 
2 

76 

66 

63 
33 
31 

1 
8 

7 

7 
6 
5 
7 
1 
2 

2 

24 

263 

32 
3 
1 

1 

18 
109 

503 

1 

3 

"i' 
1 

1 

1' 
i 

9 

5 

10 

7 
7 
4 

1 

1 

1 
1 
1 

'4 
27 

i 

13 

51 

4 

5 
i 

1 

7 

1 

1 

4 

17 

4 

2 
3 

1 

1 

6 

1 

1 

2 

15 

2 

1 
2 
3 

fi 

2 
9 

2 

"2 
1 
1 

4 
'2 

8 

5 
6 
5 
8 
1 
1 
2 

"i 

1 

"3 
33 

2 
i' 
'2' 

8 
55 

8 
7 
4 
2 

'2 
1 

1 
1 
2 
1 

i 
"3 

32 

4 
2 

'3 
11 

5-8^ 

"i 
2 

i 

4 

'2 

7 

2 
1 

3 

6 

2 

"3 

12 

4 

1 

'2' 

7 

3 

1 
5 

DEAF-DUMBNESS.  457 

returns,  35  persons  became  deaf  and  dumb  from  this  cause.  In  the  Ameri- 
can Table,  scarlet  fever  produced  deaf-dumbness  44  times  in  787  cases ;  but 
several  of  the  63  specified  causes  in  that  Table  will  not  bear  a  medical 
scrutiny,  and  many  of  them  were,  no  doubt,  taken  upon  the  hearsay  evi- 
dence of  friends.  In  the  Table  compiled  by  Dr.  Sauveur  for  the  Belgian 
statistics,  scarlatina  was  a  cause  of  muteism  in  216  cases  out  of  1892.  Per- 
foration, or  even  total  removal  of  the  membrana  tympani,  and  the  malleus 
and  incus,  will  not  of  necessity  produce  total  deafness,  but  the  stapes  cannot 
be  lost,  or  the  fenestra  rotunda  ulcerated  or  otherwise  seriously  injured, 
without  the  cavity  of  the  internal  ear  being  exposed,  the  perilymph  conse- 
quently lost,  and  by  extension  of  inflammation  the  membranous  labyrinth 
and  auditory  nerve  more  or  less  affected.  Neither  medicine  nor  mechanical 
art  can  avail  in  restoring  an  ear  so  affected,  or  in  any  way  improving  the 
hearing  of  a  person  so  circumstanced }  although  great  improvement  may  be 
obtained  by  the  introduction  of  an  artificial  membrana  tympani,  in  eases 
where  the  natural  membrane  has  been  removed,  but  in  which  the  labyrinth 
is  unaffected.  It  is  scarcely  necessary  to  remark,  that  unless  the  patient 
can  hear  loud  noises  in  his  vicinity,  all  efforts  at  treatment  wiM  be  un- 
availing.' 

The  remaining  items  in  this  class  might  all  come  under  the  same  general 
head;  they  include  inflammations  or  injuries  of  the  parts  appertaining  im- 

'  While  this  sheet  was  preparing  for  press,  I  received  Mr.  Toynbee's  tract  "  On  the 
Use  of  an  Artificial  Membrana  Tympani  in  Cases  of  Deafness  dependent  upon  Perfora- 
tion or  Destruction  of  the  Natural  Organ,"  in  which  he  has  given  a  description  and 
figures  of  the  little  instrument  to  which  I  have  alluded  at  page  298.  This  artificial 
membrana  tympani,  manufactured  by  Mr.  Weiss,  consists  of  a  thin  layer  of  gutta  percha 
or  vulcanized  India  rubber,  held  between  two  very  small  disks  of  silver,  "  about  three 
quarters  of  a  line  in  diameter,"  to  the  outer  surface  of  one  of  which  a  fine  silver  wire 
stem,  an  inch  and  a  quarter  long,  is  attached.  Another  "kind  of  artificial  membrane  is 
made  by  fijcing  the  layer  of  gutta  percha  or  vulcanized  India  rubber  between  two  very 
delicate  silver  rings,  from  the  eighth  to  the  sixth  of  an  inch  in  diameter;  these  rings  are 
rivetted  together,  leaving  a  portion  of  the  membrane  drawn  moderately  tense  in  their 
centre;  a  margin  of  the  membrane  is  also  left  beyond  the  circumference  of  the  rings,  so 
as  to  prevent  the  latter  being  in  contact  with  and  irritating  the  tube  of  the  ear.  To  the 
surface  of  one  of  these  rings  the  silver  wire  is  fixed  by  two  branches,  and  they  should 
be  joined  so  that  the  outer  surface  of  the  rings  should  look  obliquely  outwards  and  for- 
wards instead  of  directly  outwards,  thus  imitating  the  direction  of  the  natural  membrana 
tympani.  This  kind  of  membrane  is  often  preferable  to  that  previously  described,  if 
the  meatus  is  sufficiently  large  to  admit  of  its  passage."  The  surgeon  can  cut  the  gutta 
percha  or  India  rubber  to  the  requisite  size,  and,  having  moistened  it  with  water,  then 
pass  it  down  so  as  to  rest  against  any  remains  of  the  natural  membrane  which  may 
exist.  Mr.  Toynbee  has  afforded  several  cases  showing  its  applicability.  It  is  certainly 
a  much  cleaner  procedure  than  the  wool  or  cotton  previously  in  use ;  but  how  far  it- 
may  be  equally  applicable  in  the  hands  of  the  patient,  or  among  the  lower  orders, 
remains  yet  to  be  determined ;  it  is,  however,  a  most  ingenious  contrivance. 


458  APPENDIX. 

mediately  to  the  organs  of  hearing.  Ten  of  these  were  special  diseases  of 
the  ears,  generally  attended  by  otorrhoea,  among  which  I  have  classed  three 
cases  attributed  to  diseases  of  the  eyes.  These  were  instances  of  young 
persons  of  whom  it  was  related  that  they  first  became  blind,  and,  having 
remained  so  for  a  considerable  time,  then  recovered  sight,  and  immediately 
afterwards  became  deaf  and  dumb, — I  presume  either  by  metastasis  of  the 
inflammation  from  the  eyes  to  the  ears,  or  owing  to  the  same  scrofulous 
tendency,  which  induced  the  ocular  affection,  having  set  up  morbid  action 
in  the  tympanum  or  its  membranes.  In  all  the  Tables  of  any  note  which 
have  as  yet  been  published,  showing  the  causes  of  acquired  deaf-dumbness, 
an  item  for  ophthalmia  will  be  found,  but  it  is  evident  that  no  ocular  dis- 
ease could  induce  that  affection.  I  have  given  an  account  of  this  disease, 
with  illustrative  cases,  under  the  head  of  "Otitis  in  connexion  with  Oph- 
thalmia,^' at  page  265. 

The  entire  number  in  this  first  section  amounts  to  76,  the  females  pre- 
dominating over  the  males  by  one-fourth,  probably  from  the  circumstance 
of  the  former  being  more  weakly,  and  consequently  more  liable  to  the  dele- 
terious effects  of  the  diseases  specified. 

In  the  second  section  are  included  those  diseases  and  accidents  which 
acted  directly  or  indirectly  through  the  nervous  system.  The  most  nume- 
rous are  paralysis  and  fever,  the  former  including  those  complications  of  ' 
muteism  already  referred  to  at  pages  268  and  326.  Fevers  of  different 
kinds,  typhus,  gastric,  worm,  &c.,  and  endemic  to  different  countries, — are, 
in  all  the  Tables  which  I  have  examined,  one  of  the  most  prevalent  causes 
of  deafness  amounting  to  total  loss  of  hearing.  66  cases  are  attributed  to 
this  cause  in  the  Irish  returns,  and  in  a  country  where  typhus  prevails  so 
extensively,  it  is  a  matter  of  surprise  that  so  few  cases  have  resulted  there- 
from. Perhaps  the  circumstance  that  infants  or  very  young  children  do  not 
contract  that  disease  so  readily  as  adolescents  or  grown-up  persons,  and  that 
consequently  those  attacked  having  been  at  the  time  of  adult  age,  they 
never  completely  lost  the  power  of  speech,  although  many  are  partially  deaf 
from  this  cause, — may  account  for  this  peculiarity.  Of  the  pathology  of 
this  disease,  as  well  as  of  acquired  dumbness  from  fever,  I  have  already 
written  at  page  327.  We  require,  however,  more  extensive  post-mortem 
examinations  than  have  been  as  yet  recorded,  to  determine  whether  the 
deafness  resulting  from  this  cause  is  owing  to  local  inflammation,  some  cere- 
bral lesion,  or  the  general  shock  given  to  the  nervous  system.  Hydrocepha- 
lus, epilepsy,  and  convulsions,  organic  disease  of  the  brain,  and  cerebral 
affections  unspecified,  taken  together,  produced  deaf-muteism  in  58  cases. 
In  33  instances,  fright,  or  some  sudden  shock  to  the  nervous  system,  has 
been  recorded  as  the  cause  of  deaf-dumbness.  With  these  may  be  included 
cases  returned  as  "  suddenly  struck,"  or  superstitiously  attributed  to  some 
supernatural  cause,  in  which  the  account  given  by  the  friends  generally  is. 


DEAF-DUMBNESS.  459 

that  the  child  awoke  with  a  fit  of  screeching,  and  never  spoke  afterwards. 
I  have  met  some  cases  of  total  deafness  in  adults  and  young  persons  where 
this  had  occurred,  and  in  whom  nothing  abnormal  could  be  discovered  in 
the  organs  of  hearing,  neither  was  there  any  apparent  disease  of  the  brain 
to  account  for  the  complete  loss  of  hearing.  Other  cases  were  the  result  of 
fright,  caused  by  ignorant  or  ill-disposed  persons.  Partial  drowning,  or 
sudden  immersion  in  water,  should,  I  think,  be  classed  under  the  head  of 
nervous  shock.  We  had  7  cases  of  deaf-muteism  resulting  from  it  in  our 
Irish  returns  ;  and  in  the  American  Table,  3  cases  are  attributed  to  "  falling 
in  the  water."  The  effect  of  severe  or  extensive  burns  may  likewise  be 
classed  under  this  head.  Injuries  of  the  head  produced  deaf-dumbness  in 
24  cases,  of  which  16  were  by  falls  from  a  height.  In  what  way  hooping- 
cough  produces  deafness,  whether  by  local  injury  to  the  ear,  such  as  often 
occurs  during  a  violent  paroxysm  of  that  disease,  or  from  its  effect  on  the 
nervous  system,  I  am  unable  to  determine.  Every  nurse  is  aware  of  the 
many  anomalous  consequences  which  follow  pertussis,  and  popularly  denomi- 
nated the  "  dregs  of  the  hooping-cough."  This  disease  has  been  specified 
as  a  cause  of  acquired  deaf-muteism  in  all  the  Tables  which  I  have  examined. 
The  entire  number  in  this  second  section  is  263 ;  the  males  exceeding  the 
females  by  8  cases. 

The  third  section  includes  those  cases  which  could  not  properly  be  placed 
among  either  of  the  foregoing  classes  :  the  cases  attributed  to  specified 
causes  therein  number  37,  the  males,  as  in  the  previous  section,  predomina- 
ting over  the  females.  "  Cold  and  exposure,"  the  chief  item  in  this  section, 
has  arisen  from  persons  "  being  caught  in  a  snow-storm,"  or  remaining 
unsheltered  during  a  severe  night.  Extreme  cold  amounts  to  a  large  figure 
in  the  published  Tables  of  this  description,  especially  in  those  for  very  cold 
countries.  Nine  out  of  the  32  cases  were  attributed  to  "  sleeping  in  the 
open  air,"  a  circumstance  believed  by  our  peasantry  to  be  highly  conducive 
to  several  maladies,  particularly  of  the  nervous  system.  In  18  instances, 
the  assigned  cause  was  "injury,"  including  a  variety  of  unspecified  acci- 
dents ;  and  in  109  of  the  whole,  while  it  was  stated  that  the  deafness  was 
acquired  after  birth,  and  the  exact  period  specified,  the  precise  accident  or 
disease  which  produced  it  could  not  be  ascertained. 

An  examination  of  the  ages  in  the  foregoing  Table  shows  that  the  chances 
of  acquiring  muteism  lessen  as  life  advances.  It  is  stated  in  books,  that 
deaf-dumbness  is  frequently  induced  by  diseases  affecting  infants  under  one 
year  old.  When  disease  of  the  ear  is  manifest  in  such  cases,  this  may  be 
so ;  but  I  cannot  subscribe  to  the  doctrine  in  any  other  case,  unless  it  can 
be  satisfactorily  proved  that  the  infant  heard  previously.  Of  the  total  503 
cases, — in  120,  the  disease  which  produced  the  deafness  occurred  between 
birth  and  the  completion  of  the  third  year,  chiefly,  in  fact,  during  the 
second  year;  in  109,  between  the  third  and  fourth  years ;  in  76,  during  the 


460  APPENDIX. 

fourth;  38,  in  the  fifth;  36,  in  the  sixth;  32,  in  the  seventh;  21,  in  the 
eighth;  11,  in  the  ninth;  15,  in  the  tenth;  33,  during  the  five  following 
years;  and  12,  after  the  age  of  fifteen. 

Is  deaf-dumbness  curable  ?  To  this  serious  question  I  must  reply  in  the 
negative.  Except  by  miraculous  interference,  I  d'o  not  believe  the  true 
congenital  deaf-mute  was  ever  made  to  hear ;  and  those  who  lose  their  hear- 
ing so  early  in  life  as  never  to  have  acquired  the  faculty  of  speech  come 
into  the  same  category.  If  the  persons  have  ever  spoken,  every  possible 
pains  should  be  taken  to  keep  up  their  articulation,  even  although  they  may 
not  be  able  to  hear  themselves  speak ;  for  the  most  marked  difference  may 
be  observed  between  the  articulation  of  those  mute  from  birth  and  such  as 
have  ever  spoken.  Many  instances  of  the  so-called  cures  of  deaf-dumb 
persons  will  be  found  in  the  records  of  literature,  both  professional  and 
general,  and  they  have  been  collected  by  several  modern  writers,  so  that 
they  are  accessible  to  all.  They  may  be  divided  into  the  following  : — The 
education  of  the  ear,  by  the  ringing  of  bells,  and  other  similar  means  for 
producing  the  most  penetrating  sounds,  so  as  to  stimulate  the  sense  of  hear- 
ing !  This  was  one  of  the  experiments  of  Itard.  Surgical  manipulation 
has  been  had  recourse  to  for  the  cure  of  this  malady  :  the  membrana  tym- 
pani  has  been  perforated,  and  instruments  passed  through  the  Eustachian 
tubes,  in  order  to  relieve  the  deaf  and  dumb,  and  both  Itard  and  Deleau 
endeavored  to  give  hearing  by  forcibly  injecting  the  tympanic  cavity  with 
a  jet  of  air.  Galvanism  and  electricity  have  had  their  advocates.  Moxa, 
the  actual  cautery,  setons,  and  other  means  of  counter-irritation,  have  also 
been  highly  extolled.  Of  late  years,  mesmerism  has  been  employed  as  a 
remedy  for  this  affection ;  and  not  long  since  a  deaf  and  dumb  child  was 
brought  to  my  house  by  its  mother,  in  order  that  I  might  inform  her  how 
long  she  should  continue  to  administer  to  him  the  globules  which  a  homoeo- 
pathic physician,  who  has  since  left  this  city,  had  given  her,  with  the  full 
assurance  that  they  would  in  time  effect  the  much  wished-for  object.  Cur- 
tis states,  in  one  of  his  clinical  reports,  that  he  cured  three  deaf-dumb  per- 
sons ;  but  he  does  not  afford  their  names  or  residences,  nor  does  he  make 
known  the  means  which  he  employed.  The  Messrs.  Chambers  assert,  that 
Dr.  Turnbull  cured  the  deaf-dumb  by  means  of  an  alkali  dropped  into  the 
external  meatus.  The  attempts,  related  in  their  periodical,  were,  however, 
fully  exposed  by  Mr.  Kinniburgh,  as  already  alluded  to  at  page  56 ;  and 
Mr.  Baker,  whose  labors  are  specified  at  page  421,  also  drew  public  atten- 
tion to  the  attempted  cures  of  deafness,  in  one  of  the  numbers  of  the  Glas- 
gow Herald  for  1831.  In  that  publication,  in  the  appendix  to  Mr.  Scott's 
work  on  the  deaf  and  dumb,  in  that  admirable  repertorium  of  science,  Silli- 
man's  Journal  for  1836,  in  the  third  volume  of  the  American  Annals,  and 
in  the  works  of  Schmalz,  Kramer,  Pfingsten,  and  Williams,  will  be  found 
most  of  the  so-called  cures  of  deaf-dumbness.      Let   any  one   carefully 


DEAF-DUMBXESS.  461 

examine  the  details  of  the  cases,  garbled  as  they  are,  and  then  say  whether 
he  really  believes  the  statements  put  forth.  Let  us  take  up  one  of  those 
reputed  cures,  and  analyze  the  process  by  which  hearing  was  supplied  to  a 
person  in  whom  that  sense  was  wanting,  fi'om,  in  all  probability,  imperfect 
development  in  the  internal  ear,  or  disorganization  of  the  apparatus  of 
hearing, — as,  for  instance,  the  vaunted  cures  of  Felix  Merle,  whose  secret 
remedy  Itard  endeavored  to  purchase  :  it  was  found  to  consist  of  assarabica, 
rose-leaves,  horse-radish,  parsely  pert,  white  wine,  and  sea-salt !  !  In  con- 
clusion, I  must  say  I  do  not  think  it  honest  in  any  legalized  practitioner  to 
attempt  the  cure  of  complete  deaf-dumbness,  notwithstanding  the  advice  of 
Mr.  Williams,  that  "  a  cure  ought  ahcai/s  to  be  attempted."  Two  or  three 
instances  have,  however,  been  recorded,  in  which  persons  previously  mute 
became  spontaneously  gifted  with  hearing,  and  who  subsequently  spoke. 
One  of  these  is  that  related  in  the  Memoirs  of  the  French  Academy  of 
Science  in  1703,  in  which  a  man  previously  dumb  began  to  speak  at  the  age 
of  24;  and  another,  related  by  M.  Le  Bousoyer  Desmortier,  in  which  a 
young  man,  twenty-eight  years  of  age,  who  was  previously  dumb,  acqxiired 
hearing  and  speech.  A  third  instance  of  a  similar  effect  is  recorded  in  the 
twenty-fifth  volume  of  the  Philosophical  Transactions.  The  history  of 
Dickory  Croncke,  related  by  De  Foe,  to  which  I  have  already  alluded,  is  of 
this  class. 

I  have,  as  already  stated  at  page  169,  seen  diseases  of  the  ear  among  the 
lower  animals.  '  Sporting  dogs  sometimes  become  quite  useless  from  the 
amount  of  deafness  under  which  they  labor.  Hoffman  mentions  an  instance 
of  a  dog  blind  and  deaf  on  the  right  side,  in  which  the  corresponding  optic 
and  acoustic  nerves  were  atrophied  and  of  a  yellow  color.  How  far  con- 
genital muteism  may  extend  throughout  the  animal  creation  has  not  yet  been 
determined.  An  instance  is  related  by  the  Rev.  Mr.  Bree  of  a  white  Per- 
sian cat,  with  blue  eyes,  which  was  completely  deaf: — "She  produced  at 
various  times  many  litters  of  kittens,  of  which  some  were  quite  white  ; 
others  more  or  less  mottled,  tabby,  &c.  But  the  extraordinary  circumstance 
is,  that  of  the  offspring  produced  at  one  and  the  same  birth  : — such  as  were 
like  the  mother,  entirely  white,  were,  like  her,  invariably  deaf;  while  those 
that  had  the  least  speck  of  color  on  their  fur  as  invariably  possessed  the  usual 
faculty  of  hearing."  I  have  not  read  of  any  instance  of  a  mute  albino  in 
the  human  race ;  but  I  have  observed  albinoes  in  families,  other  members 
of  which  were  mute,  and  in  which  the  parents  were  related. 

Among  the  lower  orders  there  are  many  superstitions  regarding  the  deaf 
and  dumb,  who  are  believed  to  be  otherwise  gifted,  as  a  compensation  for 
their  misfortune.  This  idea  is  generally  turned  to  account,  particularly  by 
strolling  dumb  beggars,  in  fortune-telling,  charm-working,  and  in  the 
discovery  of  theft.  Muteism  is  on  this  account  often  assumed ;  and  many 
impostors  have  been  detected  in  this  character.     Dalyell,  in  his  "  Darker 


462  APPENDIX. 

Superstitions  of  Scotland,"  says  : — ''  In  this  country  the  faculty  of  predic- 
tion has  been  associated  with  the  dumb ;  and,  as  of  old,  it  originated  from 
a  vision.  The  devout  connected  some  communion  with  the  Deity,  or  with 
the  ethereal  world,  during  suspension  of  human  faculties.  Thence  Daniel, 
in  a  vision,  '  became  dumb ;'  and  Zacharias,  a  priest,  was  speechless  for 
nine  months  from  having  seen  a  vision  in  the  temple."  The  popular  terms 
for  deaf-dumbness  are  : — Deaf  and  dumb ;  a  dummy ;  the  silent  people  ; 
mute ;  and,  in  the  Irish  tongue,  hodhar  agus  balbh,  "  deaf  and  dumb." 

It  is  often  difficult  to  discover  whether  the  person  is  really  deaf  and  dumb, 
and  several  people  have  carried  on  the  deception  for  years.  Sir  Walter 
Scott's  character  of  Fenella,  in  "Peveril  of  the  Peak,"  is  a  well-dr^Iwn  in- 
stance of  long-sustained  deception  of  this  nature.  Sometimes,  however,  the  im- 
posture has  been  detected  by  so  simple  a  means  as  suddenly  asking  persons 
how  long  they  were  dumb.  Sicard  is  said  to  have  detected  an  assumed 
mute  who  was  accused  of  some  offence,  by  causing  him  to  write, — his  spell- 
ing showing  that  he  had  learned  by  ear,  and  not  by  sight.  The  man  was 
convicted  on  this  evidence;  but,  in  my  opinion,  most  unjustly;  for,  as 
every  teacher  of  the  deaf  and  dumb  is  well  aware,  even  the  most  educated 
of  that  class  make  errors  in  spelling  as  well  as  orthography. 

Is  the  mortality  greater  among  the  deaf  and  dumb  than  the  rest  of  the 
community  with  whom  they  happen  to  be  placed ;  and  are  mute  persons 
more  liable  than  others  to  particular  diseases  ?  The  only  answer  to  this 
question  is  that  afforded  by  the  recent  Irish  Census  returns.  From  the  30th 
of  March,  1851,  to  the  29th  of  February,  1852,  77  mute  persons  (35  males 
and  42  females)  died, — that  number  being  about  the  average  mortality  in 
4151  persons,  at  all  ages,  in  this  country,  for  eleven  months,  or  nearly  1  in 
50  per  annum.  In  addition  to  these,  many  other  deaths  of  deaf  mutes 
were  afforded  by  the  returns,  in  which  the  diseases,  ages,  and  sexes,  were 
specified, — in  all  amounting  to  291 ;  and  the  Table  formed  thereon,  although 
it  affords  no  additional  evidence  to  the  foregoing  as  to  the  rate  of  mortality, 
yet  enables  us  to  form  a  well-founded  opinion  as  to  the  most  prevalent  dis- 
eases and  casualties  among  this  class.  Of  217  deaths,  of  which  the  causes 
were  specified,  72  occurred  from  zymotic  diseases, — the  two  heaviest  items 
among  which  were,  fever,  26 ;  and  dysentery,  19.  135  occurred  from  spo- 
radic diseases;  among  which  consumption  bore  an  undue  proportion,  preva- 
lent as  that  disease  is  in  the  British  isles,  and  thus  confirms  the  oft-ex- 
pressed opinion,  that  deaf-muteism  is  but  one  of  the  varieties  of  struma  :  77 
deaths  (34  of  males  and  43  of  females)  were  registered  under  that  head. 
The  females  predominated  in  this  class  over  the  males  by  15;  whereas  the 
males  exceed  the  females  almost  as  2  to  1  when  the  deaths  occurred  from 
epidemic  diseases.  Ten  cases  were  registered  under  the  head  of  "  Violent 
or  sudden  deaths."  Large  as  this  proportion  seems  at  first  sight,  it  will 
not  appear  too  much  when  we  take  into  account  the  greater  liability  to  ac- 


DEAF-DUMBNESS.  463 

cidents  of  persons  altogether  devoid  of  hearing.  It  would  form  an  inte- 
resting subject  of  inquiry,  and  one  which  I  hope  will  have  due  weight  with 
future  investigators,  to  ascertain  whether  there  is  a  greater  amount  of  mor- 
tality among  uneducated  than  educated  deaf  mutes  :  we  require,  however,  a 
much  more  extended  field  of  inquiry,  and  a  greater  accumulation  of  facts, 
than  have  as  yet  been  recorded  upon  this  subject,  to  be  in  a  position  to  ofi'er 
an  opinion  thereon. 

It  now  only  remains  briefly  to  allude  to  some  of  the  questions  which,  in 
a  legal  point  of  view,  afiect  the  deaf  and  dumb.  Modern  divines  have  not, 
so  far  as  I  am  aware,  laid  down  any  dogmas  with  respect  to  the  position  in 
a  religious  point  of  view  of  an  uninstructed  deaf  mute  ;  but  that  an  edu- 
cated mute  may  be  admitted  to  all  the  privileges  of  the  Roman  Catholic 
Church  we  learn  from  the  fact  related  by  De  Ponce,  that  one  of  his  pupils 
took  orders,  and  possessed  a  benefice  (see  p.  416).  With  respect  to  baptism, 
the  question  can  seldom  arise  owing  to  the  infancy  of  the  mute ;  but  even 
in  the  case  of  adults,  provided  others  make  profession  for  them,  it  is  stated, 
in  J.  Paulo  Lancellotto's  "  Institutionum  Juris  Canonici,"  that  they  can  be 
baptized.  Deaf-mute  persons  may,  according  to  our  present  ecclesiastical 
law,  contract  marriages,  in  which  they  may  give  their  consent  by  signs.  A 
deaf  mute  can  also  inherit  property,  and,  as  the  law  now  stands,  give  evi- 
dence and  make  a  will.  These  are  great  improvements  upon  the  ignorance 
and  barbarism  of  other  times,  when  the  law  regarded  the  congenital  deaf 
mute  in  the  light  of  an  idiot ;  and  even  to  this  day  the  person,  deaf,  dumb, 
and  blind  is  so  styled. 

We  have  not  heard  as  yet  a  sufiicient  amount  of  statistics  before  us  to 
say  whether  more  crimes  are  committed  by  educated  or  uneducated  deaf- 
mute  persons,  or  by  the  entire  of  this  class,  compared  with  a  similar  num- 
ber of  persons  in  the  same  walks  of  life  who  possess  both  speech  and  hearing. 
An  uneducated  deaf  and  dumb  man  was  tried  at  the  Spring  Assizes  of 
1852,  at  Downpatrick,  for  the  murder  of  his  brother,  by  stabbing  him  with 
a  knife  in  a  fit  of  passion.  The  only  means  of  making  the  prisoner  under- 
stand the  nature  of  the  proceedings,  or  the  evidence  against  him,  was  through 
the  medium  of  signs ;  for  which  purpose,  one  of  his  neighbors,  who  was 
accustomed  to  communicate  with  him,  was  employed  as  an  interpreter.  The 
man  was  found  guilty  of  manslaughter,  and  sentenced  to  twelve  months' 
imprisonment.  Another  trial  of  a  deaf  mute,  for  larceny,  occurred  in  the 
same  place  in  1840  ;  and  a  similar  course  was  pursued.  See  Crawford  and 
Dix's  Reports,  p.  402.  A  third  deaf-dumb  person  was  also  tried  for  theft 
at  Downpatrick  in  1852,  but  he  was  educated,  and  pleaded  guilty.  Accord- 
ing to  the  Brehon  Laws,  a  deaf  mute  could  not  appear  in  any  way  in  a 
court  of  justice. 

Herder,  in  his  "  Philosophic  der  G-eschicte  der  Menschheit,"  says  : — "The 
history  of  uneducated  deaf  mutes  shows  how  rarely  men  can  rise  to  the 


464  APPENDIX. 

exercise  of  reason  when  deprived  of  the  faculty  of  speech  :  they  remain,  in 
fact,  within  the  mere  limits  of  animal  instinct.  A  deaf  mute  will  imitate 
whatever  he  sees,  whether  good  or  bad,  just  like  a  monkey;  though  he  is, 
indeed,  sunk  lower  even  than  the  animal,  for  the  instinct  of  sympathy  with 
his  own  race  is  wanting  in  him."  As  an  instance  of  this,  he  cites  the  case 
of  a  born  deaf  mute  who  murdered  his  brother  after  he  had  seen  a  pig 
killed,  simply  from  the  instinct  of  imitation,  and  even  rooted  in  the  entrails 
with  a  savage,  senseless  pleasure ;  and,  adds  the  author — ''  This  is  a  horri- 
ble proof  how  little  our  vaunted  human  reason  and  sympathy  with  our 
species  can  effect  when  dissevered  from  the  faculty  of  speech." 

When  bills  of  indictment  have  been  found  against  a  prisoner  by  the 
Grand  Jury,  he  is  then  arraigned  at  the  bar,  desired  to  hold  up  his  hand, 
to  answer  to  the  name  under  which  he  is  indicted,  and  called  upon  to  plead. 
If,  upon  his  arraignment,  the  prisoner  does  not  answer,  it  becomes  a  ques- 
tion whether  he  does  so  of  malice,  or  is  mute  by  the  visitation  of  Grod. 
The  court  will,  in  such  a  case,  direct  a  jury  to  be  impannelled,  who  are 
immediately  taken  by  the  sheriff  from  the  bystanders ;  a  special  form  of 
oath  is  administered  to  them,  and  the  prisoner's  counsel  may  call  witnesses 
as  to  the  fact  of  muteism,  &c.  Where  the  jury  find  a  verdict  of  "  mute  by 
the  visitation  of  God,"  and  that  the  prisoner  is  of  competent  intellect,  and 
can  be  made  to  understand  the  nature  of  the  proceedings  against  him,  the 
trial  may  proceed.  If  the  prisoner  can  read  and  write,  he  is  handed  the 
indictment,  and  the  usual  questions  are  addressed  to  him  in  writing.  After 
he  has  pleaded,  and  stated  in  writing  that  he  has  no  objection  to  any  of  the 
jury,  the  trial  may  proceed.  The  judge's  notes  of  the  evidence  are  given 
to  him  after  the  examination  of  each  witness,  and  he  is  allowed  to  put 
questions  in  writing ;  but  if  the  prisoner  is  uneducated,  then  some  one, 
either  in  the  habit  of  communicating  with  the  deaf  and  dumb,  or  acquainted 
with  the  prisoner's  peculiar  mode  of  signing,  is  usually  employed  to  explain 
to  him  the  nature  of  the  evidence,  &c. 

When  a  deaf  and  dumb  prisoner  cannot  be  made  to  comprehend  the 
nature  of  the  proceedings  and  the  details  of  the  evidence,  the  usual  course 
is,  after  the  jury  have  found  him  "  mute  by  the  visitation  of  God,"  to  re- 
impannel  the  jury,  to  inquire  whether  he  is  able  to  plead  to  the  indictment : 
and  if  that  issue  be  found  in  the  affirmative,  then  they  are  re-sworn  again 
to  inquire  if  the  prisoner  be  sane  or  not;  and  if  the  jury  find  him  insane, 
the  judge  will  order  him  to  be  confined  under  the  statute  in  that  case  made 
and  provided.  But,  suppose  the  jury  find  that,  although  sane,  he  is,  from 
incompetency  and  want  of  education,  unable  to  plead,  he  cannot  by  the 
common  law  be  put  upon  his  trial;  but  the  judge  may  order  him  to  be  kept 
in  confinement,  as,  peradventure,  he  may  at  some  future  period  be  made  to 
understand  the  nature  of  the  charge. 

Thus  "  there  are  three  points  to  be  inquired  into  in  all  such  cases :  first, 


DEAF-DUMBNESS.  465 

whether  the  prisoner  is  mute  of  malice  or  not;  second,  whether  he  can 
plead  to  the  indictment  or  not ;  third,  whether  he  is  of  sufficient  intellect 
to  comprehend  the  course  of  proceedings  at  the  trial  so  as  to  make  a  proper 
defence."^ 

A  witness,  though  deaf  and  dumb,  may  be  sworn,  and  give  evidence  upon 
an  indictment,  if  intelligence  can  be  conveyed  to  and  received  from  him  by 
means  of  signs  and  tokens. 

'Alderson,  B.,  Pritchard's  case,  7  Carrington  and  Payne's  Reports,  503.  See  also 
Dyson's  case,  ibid.  305. 


To  the  instances  of  persons  deaf,  dumb,  and  blind,  alluded  to  at  page 
447,  may  be  added  the  interesting  case  of  Margaret  Sullivan,  of  the  Rother- 
hithe  Workhou.se,  related  by  Dr.  R.  Fowler,  in  two  papers  read  to  the 
British  Association,  and  printed  in  the  Reports  of  that  body  for  the  years 
1841  and  1842 ;  and  also  in  "  Some  Observations  on  the  Mental  State  of 
the  Blind  and  Deaf  and  Dumb,"  suggested  to  that  author  by  the  foregoing 
case  (Salisbury :  1843). 


30 


INDEX. 


Abekceombie,  Dr.,  his  cases  and  writings,  I 
329,  403. 

Abscess,  chronic,  of  mastoid  region,  177;  i 
in  external  meatus,  191 ;  in  membrana  ' 
tympani,  222 ;  of  brain,  said  to  produce 
otorrhcea,  408. 

Acid,  nitric,  poured  into  the  ear,  fatal  case 
of,  314. 

Acids,  effect  of,  in  the  meatus,  184. 

Acquired  deaf-muteism,  causes  of,  485. 

Adults,  deaf  dumb,  institution  for,  428. 

African  tribes,  their  mode  of  ornamenting 
the  ear,  167. 

Age,  deafness  attendant  upon,  260. 

Agricola  Rodolphus,  his  work  on  muteism, 
415. 

Air-globule  in  perforate  membrana  tym- 
pani, 216. 

Air-globules,  a  diagnostic  in  otorrhoea,  290. 

Air-press,  75,  79. 

Alphabet  manual,  418,  431. 

America,  deaf-dumb,  in,  435. 

American  annals  of  the  deaf  and  dumb, 
430;  institutions  for  the  deaf  and  dumb, 
429  ;  statistics,  435. 

Amman,  Dr.  J.  C,  an  instructor  of  the 
deaf  and  dumb,  417. 

Anatomy  of  the  external  ear,  155  ;  mem- 
brana tympani,  209 ;  cavitas  tympani, 
299;  Eustachian  tube,  306;  labyrinth, 
353. 

Anecdotes  of  the  deaf  and  dumb,  Orpen's, 
425. 

Aneurism,  post-aural,  178. 

Animals,  deaf-dumb,  461. 

Annals,  American,  of  the  deaf  and  dumb, 
418. 

Anti-helix.     See  Auricle. 

Anti-tragus.     See  Auricle. 

Aperture,  natural,  in  membrana  tympani, 
214. 

Aqueduct  of  Fallopius,  213,  301. 

Aqueduct  of  the  cochlea,  354. 

Aqueduct  of  the  vestibule,  355. 

Arnica,  its  value  in  aural  diseases,  103,  248. 

Arnold's  plates  of  the  ear,  30,  215  ;  gan- 
glion, 309. 

Arrowsmith's  work  on  the  instruction  of 
the  deaf  and  dumb,  423. 

Arteries  of  membrana  tympani,  215,  216  ; 
of  the  tympanum,  310  ;  of  the  labyrinth, 
355. 


Artery,  anterior  auricular,  156  ;  temporal, 
156  ;  artery,  posterior  aural,  158. 

Articulating  system,  417,  421,  431. 

Artificial  membrana  tympani,  295. 

Artillery,  firing  of,  a  cause  of  aural  hemor- 
rhage, 219,  220. 

Atheromatous  deposits  in  membrana  tym- 
pani, 276. 

Auditory  canal,  external,  mode  of  examin- 
ing, 67  ;  alterations  in,  199. 

Aural  diseases,  what  attributed  to,  145. 

Aural  surgeon,  requisites  for,  60. 

Aural  surgery,  history  of,  21 ;  contributions 
to,  62. 

Auricle,  diseases  of,  140,  151 ;  anatomy  of, 
154,  157;  double,  161  ;  wounds  and  inju- 
ries of,  164  ;  tumors  of,  166,  168;  inflam- 
mations of,  169  ;  erysipelas  of,  169. 

Auscultation,  aural,  74. 

Avery,  his  reflector  (invented  by  M.  Sega- 
ias),  70.  See  Medical  Times  and  Gazette 
for  25th  Dec,  1852,  p.  651. 

Bacon,  a  popular  remedy  for  ear  diseases, 

19,  250. 
Baker,  C,  his  writings  upon  the  deaf  and 

dumb,  423,  460. 
Baker,  Henry,  a  teacher  of  the  deaf   and 

dumb,  421. 
Ball's  dissertation  on  the  ear,  36. 
Banks,  Dr.,  his  case  of  fatal  otorrhcBa,  407. 
Bathing,  a  cause  of  otorrhcea,  379. 
Beck,  on  outward  pressure  of  membrana 

tympani,  278 
Bede,  on  deaf-dumbness,  415,  418. 
Belfast    institution   for    deaf,    dumb,   and 

blind,  426. 
Belgium,  deaf-dumbness,  in,  430,  432,  440. 
Bell's  paralysis,  331. 
Bell,  Sir  C,  on  loss  of  speech  and  hearing, 

328  ;  on  facial  paralysis,  333. 
Bennett's  translation  of  Kramer,  41,  365. 
Bird,  Dr.  F.,  on  ear  disease  among  the  in- 
sane, 169. 
Bleeding  from  the  ear,  179. 
Blind,  deaf,  and  dumb,  447,  465. 
Blood  coagulated  in  tympanum,  283. 
Blushing  of  the  ears,  165. 
Bones  of  the  ear,  302. 
Bonet,    Theophilus,   his    observations    on 

aural  pathology,  25. 
Bonet,  J.  P.,  his  work  on  muteism,  416. 


468 


INDEX. 


Borg's  school  at  Lisbon,  417. 
Bougies,  Eustachian,  83,  348. 
Bozzini's  mirror  for  aural  inspection,  68. 
Brace,  Julia,  mute  and  blind,  448. 
Braidwood,  Thomas,  first  Scotch  instructor 

of  the  deaf  and  dumb,  420,  424. 
Brain,  diseases  of,  a  cause  of  deafness  and 

dumbness,  489. 
Bree's,  Mr.,  case  of  deaf-dumb  cats,  492. 
Brehon  Laws  on  deaf-dumbness,  463. 
Bridgman,  Laura,  education  of,  448. 
Britain,  institutions  for  the  deaf  and  dumb 

in,  422,  424,  430. 
Buchanan,  Mr.  T.,  his  works  upon  the  ear, 

39;    his  lamp,  68;    his  classification  of 

aural  diseases,  146. 
Buchner's  work  on  the  deaf  and  dumb,  422. 
Buffon's  opinion  of  Pereira,  418. 
Bulwer,  Dr.  J.,  his  chirologia,  &c.,  418. 
Burnett,  Bishop,  his  writings  on  the  deaf 

and  dumb,  419. 
Butcher,    Dr.,  his  cases  of  perforation  of 

membrana  tympani,  286. 


Cabra  school  for  deaf- dumb,  426. 

Cadmus,  428. 

Calcareous  deposits  in  membrana  tympani, 
276. 

Camerarius,<'his  writings  on  muteism,  417. 

Canals,  semicircular,  anatomy  of,  354. 

Cancer  of  the  ear,  207. 

Cannon-firing,  its  effect  on  the  ear,  280. 

Carden,  Jerome,  on  the  instruction  of  the 
deaf  and  dumb,  415. 

Caries  of  internal  ear,  353  ;  of  mastoid 
process,  399. 

Carion,  E.  de,  an  instructorof  the  deaf  and 
dumb,  417. 

Carotid  canal,  306 ;  artery,  ulceration  of, 
326  ;  tied  for  aural  hemorrhage,  326. 

Cartilages  of  ear,  anatomy  of,  154,  160. 

Cartilaginous  ring  in  the  membrana  tym- 
pani, 213. 

Carton,  the  Abbe,  his  writings,  415,  448. 

Catholic  institution  for  deaf-dumb  in  Dub- 
lin, 426. 

Case  ofmalformationof  meatus,  163;  fibrous 
tumor  of  auricle,  166  ;  anomalous  tumor 
of  meatus,  168  ;  chronic  erysipelas  of 
auricle,  169;  eczema  aurium,  171;  sub- 
aural  tumor,  176  ;  aneurism  of  post-aural 
artery,  178;  inflammation  of  meatus,  195; 
closure  of  meatus,  199  ;  condyloma  of 
meatus,  202  ;  tumor  in  meatus  202 ;  ex- 
ostosis of  meatus,  204. 

Cases,  mode  of  recording,  64;  registry  of, 
120, 139  ;  of  disease  of  cerumenous  glands, 
189,  190;  of  malignant  disease  of  ear,  205, 
206  ;  laceration  of  membrana  tympani, 
218,  223;  facial  paralysis,  220,  331  ;  my- 
ringitis, 234  ;  myringitis  and  tympanitis, 
239  ;  rheumatic  otitis,  242  ;  subacute  my- 
ringitis, 249  ;  syphilitic  myringitis,  255. 
257  ;  strumous  myringitis,  264  ;  ophthal- 
mia, with  otitis,  266,  267 ;  thickening 
and  opacity  of  membrana  tympani, 
275  ;  collapsed  membrana  tympani,  281  ; 
diseased  membrana  tympani,  293;  artifi- 
cial membrana  tympani,  295, 296  ;  chronic 


inflammation  of  tympanum,  337,  340;  ex- 
ploration of  Eustachian  tubes,  340. 

Cassebohm,  his  book  on  the  ear,  30;  his 
case  of  double  auricles,  161. 

Castre,  Pierre  de,  his  work  on  the  deaf  and 
dumb,  417. 

Caswall,  his  work  upon  the  ear,  40. 

Catarrhal  inflammation  of  meatus,  193  ; 
otorrhoea,  388;  otitis,  333 ;  tympanitis,  334. 

Catechism  for  the  deaf  and  dumb,  424. 

Catheter,  Eustachian,  and  method  of  em- 
ploying 76-78,  81,  82. 

Cats,  deaf,  461. 

Cavitas  tympani,  classification  of  its  dis- 
eases, 152  ;  anatomy  of,  299  ;  malforma- 
tions of,  310. 

Celsus,  his  knowledge  of  ear  diseases,  22. 

Census,  Irish,  of  deaf  and  dumb,  412. 

Cerebral  diseases  causing  tinnitus  aurium, 
359. 

Cerebral  diseases  consequent  on  aural  affec- 
tions, 198  ;  from  extension  of  otitis,  319  ; 
from  otorrhcea,  402. 

Cerlatas,  Peter  de  la,  speculum  auris,  25. 

Chaissaignac  and  Robert  on  serous  effusion 
from  the  ear,  315. 

Chambers's  Journal  on  aural  surgery,  55. 

Charlotte  Elizabeth's  "  Happy  Mute,"  427. 

Cheselden's  proposal  to  perforate  the  mem- 
brana tympani,  33. 

Chevallier's  treatise  on  the  ear,  58. 

Chilblains  of  auricle,  171. 

Chimney-sweeper's  cancer  of  ear,  208. 

Chirologia,  Bulwer's,  418. 

Chloroform  in  aural  diseases,  172. 

Chomel,  M.,  on  tubercular  deposits  in  the 
ear,  359. 

Chorda  tympani  nerve,  305,  361. 

Cicatrix  in  membrana  tympani,  220. 

Cilise  in  Eustachian  membrane,  308. 

Citrine  ointment,  173. 

Claremont  Institution,  424. 

Classification  of  aural  affections,  147-153. 

Cleft  palate,  a  cause  of  deafness,  350. 

Cleland,  Archibald,  his  observations  on  the 
ear,  26,  278. 

Clerk,  Laurent,  429. 

Closure  of  external  meatus,  199. 

Cochlea,  anatomy  of,  354. 

Cod-liver  oil  in  otorrhcea,  390. 

Cogswell,  Dr.,  of  Hartford,  428. 

Cold,  a  cause  of  aural  disease,  340 ;  ex- 
treme, a  cause  of  muteism,  459. 

Cole,  Daniel,  deaf,  dumb,  and  blind,  453. 

Collapse  of  membrana  tympani,  278. 

Colles,  Dr.*A.,  his  case  of  aneurism  of  pos- 
terior auris  artery,  162 ;  on  hemorrhage 
and  fluid  evacuations  from  the  ear,  314. 

Colles,  Mr.  W.,  his  case  of  aneurism  of 
posterior  auris  artery,  178. 

Concha.     See  Auricle. 

Condyloma  of  external  meatus,  202. 

Congenital  malformations  of  auricle  and 
meatus,  160;  membrana  tympani,  217; 
cavitas  tympani  and  Eustachian  tube, 
310  ;  labyrinth,  authorities  upon,  357. 

Congenital  deafness,  437. 

Congestion,  a  cause  of  deafness,  367. 

Consanguinity,  effects  of,  442. 

Consumption  in  deaf-dumb,  462. 


INDEX. 


469 


Contrast,  the,  by  Dr.  Orpen,  424. 

Convention  of  teachers,  428,  430. 

Conve.\ity  of  membrana  tympani,  211. 

Cooper,  Sir  A.,  on  perforation  of  the  mem- 
brana tympani,  33,  34,  218,  283. 

Cooper's  Surgical  Dictionary,  article  Ear,  45. 

Copenhagen,  Institution  for  Deaf  and  Dumb 
at,  418. 

Cophosis,  362. 

Corrigan.  Dr.,  his  case  of  fatal  otorrhoea, 
408. 

Cotunno,  liquor  of,  23,  355. 

Counter-irritation  in  aural  disease,  95. 

Craig's  school  at  Kilrea,  426. 

Crampton,  Sir  P.,  his  case  of  caries  of  in- 
ternal ear,  358. 

Crescentic  opacity  of  membrana  tympani, 
274. 

Cronke,  Dickory,  a  deaf  mute,  history  of, 
420,  461. 

Crucible  for  melting  nitrate  of  silver,  292. 

Cures  of  deaf-muteism,  460. 

Curette  for  removing  foreign  bodies,  181. 

Curtis,  J.  H.,  his  works  on  the  ear,  36, 
37. 

Curvatures  of  membrana  tympani,  21. 

Cusack,  Mr.,  his  cases  of  ear  disease,  209, 
245,  399. 

Cutaneous  diseases  of  ear,  198. 

Cuthbert,  Dr.,  his  case  of  otorrhoea,  409. 

Cyclopaedias,  articles  on  deaf-dumbness  in, 
423. 

Dactology,  418,  431. 

Dalgarno,  G.,  his  writings  on  the  deaf  and 
dumb,  419. 

Dalyell's  Superstitions,  492. 

Deaf  and  dumb,  their  condition  in  early 
times,  24  ;  in  Ireland,  statistics  of,  62, 
431;  claims  of,  413;  history  of  their  edu- 
cation, 415;  marriage  of,  444;  sexes  of, 
441  ;  consanguinity  of  parents  of,  442  ; 
legal  state  of,  463. 

Deaf,  dumb,  and  blind,  447;  idiotic,  438, 
446 ;  lunatic,  446. 

Deaf-dumbness,  classification  of,  153  ;  from 
exanthema,  324  ;  acquired,  causes  of,  325; 
455 ;  appendix  on,  412  ;  literature  relating 
to,  414;  statistics  of,  432;  congenital, 
437 ;  complications  of,  439  ;  divisions  of, 
438  ;  hereditary  nature  of,  444. 

Deaf  Playmate's  Story,  334. 

Deafness  attributed  to  mercury,  102;  at- 
tending typhus  fever,  267;  nervous,  361. 

Dease's  work  on  injuries  of  the  head,  314. 

De  I'Epee's  labors  and  works,  418,  422. 

De  Foe's  Dumb  Philosopher,  329  ;  History 
of  Duncan  Campbell,  420. 

Deformities  among  deaf-dumb,  447. 

Degerando's  works  on  the  deaf  and  dumb, 
418. 

Degravers,  Peter,  his  work  on  the  ear,  29; 
perforation  of  membrana  tympani  by, 
29,  284. 

Deleau,  his  writings  upon  the  ear,  40  ;  his 
aural  inspector,  68 ;  on  artificial  mem- 
brana tympani,  296  ;  his  classification  of 
aural  diseases,  147. 

De  Lys'  Lectures,  424. 

Dentition,  its  effects  on  hearing,  309. 


Desmortier's  cure  of  dumbness,  461. 

Diagnosis  of  ear  diseases,  62. 

Dibdin's  account  of  W.  Geikie,  427. 

Dictionary  of  Practical  Medicine,  article 
Ear,  58  ;  of  Universal  Signs  for  the  Deaf 
and  Dumb,  422. 

Diffused  inflammation  of  meatus,  193. 

Digby,  Sir  K.,  his  writings  on  the  deaf  and 
dumb,  419. 

Dionysius,  form  of  his  prison,  157. 

Dislocation  of  auricle,  208. 

Diving,  a  cause  of  aural  hemorrhage,  219. 

Dogs,  diseases  of  ear  in,  169,  461. 

Doherty,  Dr.,  his  case  of  congenital  dumb- 
ness, 438. 

Donaldson's  hospital,  424. 

Douglas,  John,  his  demonstration  of  Eusta- 
chian catheterism,  28. 

Drama  of  l' Abbe  de  I'Epee,  422. 

Drowning,  partial,  a  cause  of  muteism,  459. 

Druitt,  Mr.,  his  Vade  Mecum,  21. 

Dryness  of  membrana  tympani,  217. 

Dufton,  Mr.  W.,  his  work  on  the  ear,  47. 

Dumbness  after  fever,  327;  from  otitis,  328; 
congenital,  329,  438. 

Dumb  Philosopher,  De  Foe's,  329. 

Duration  of  aural  diseases,  140. 

Dutch  writers  on  deaf-dumbness,  417. 

Dutens,  Rev.  W.,  his  article  on  the  deaf 
and  dumb,  421. 

Du  Verney,  his  works  upon  the  ear,  25,  29, 
35 ;  his  classification  of  aural  diseases, 
147;  on  otorrhoea,  384. 

Ear  and  eye,  analogy  in  diseases  of,  107. 

Ear  diseases,  statistics  of,  104,  119,  149, 
432. 

Ear  drops,  97. 

Ear,  external,  mode  of  examining  the,  65  ; 
malformations  of,  160,  164. 

Ear,  internal,  diseases  of,  353. 

Ear,  middle,  diseases  of,  310. 

Ear-rings,  piercing  lobe  for,  165. 

Earwigs,  180. 

Earle's,  Mr.  H.,  essay  on  the  ear,  39,  391. 

East  wind,  its  effect  on  the  ear,  196. 

Eczema  aurium,  105,  171. 

Edgbaston  institution,  424. 

Edmburgh,  state  of  aural  surgery  in,  59; 
first  school'for  the  deaf  and  dumb  in, 
421. 

Egyptians,  form  of  auricle  in,  158. 

Electricity  and  galvanism,  their  value,  97. 

Elliott,  S.,  his  observations  on  hearing,  31. 

England,  instruction  of  deaf-dumb  in,  418; 
424;  435.^ 

English  aurists,  26. 

Epilepsy,  from  foreign  body  in  the  ear,  313. 

Epithelial  bodies  in  meatus,  208. 

Eruptive  diseases  of  meatus,  198. 

Erysipelas  of  the  auricle,  169. 

Ether,  nitrous,  its  effect  upon  the  mem- 
brana tympani,  280;  mode  of  injecting 
into  tympanum,  369. 

Evans,  Mr.  J.,  his  case  of  syphilitic  myrin- 
gitis, 256. 

Europe,  number  of  deaf-dumb  in,  432. 

Eustachian  catheterism,  discovery  of  by  ■ 
Guyot,  26;  by  Cleland,  27- 

Eustachian  tube,  method  of  examining,  75- 


472 


INDEX. 


Lungs,  disease  of,  consequent  on  otorrhoea, 

405. 
Lupoid,  ulceration  of  auricle,  175. 


Maclagan,  Dr.,  his  case  of  epilepsy  from 
foreign  body  in  the  ear,  313. 

Magee's  school  for  deaf-dumb,  426. 

Maggots  in  the  ear,  180. 

Malformations  of  the  auricle,  160;  of  mem- 
brana  tympani,  217;  of  the  tympanum, 
310;  of  Eustachian  tube,  310;  of  inter- 
nal ear,  356. 

Malignant  disease  in  meatus,  205-207;  of 
middle  ear,  346;  of  internal  ear,  359. 

Malleus,  its  anatomy,  210,  302. 

Marsh,  Sir  H.,  his  case  of  morbid  deposit 
in  membrana  tympani,  277. 

Martin's  writings  on  the  deaf  and  dumb, 
420. 

Martineau,  Miss,  her  Deaf  Playmate's 
Story,  334  ;  hearing  trumpet,  410. 

Mason's,  Mr.,  case  of  syphilitic  myringuis, 
256. 

Mastoid  process,  perforation  of,  33  ;  mode 
of  examining,  65  ;  anatomy  of,  158  ;  clas- 
sification of  its  diseases,  151  ;  gland, 
anatomy  of,  158  ;  region,  diseases  of,  175 ; 
cells,  description  of,  301,  305  ;  inflamma- 
tion of,  219  ;  process,  diseases  of,  344 ; 
removal  of,  by  caries,  399. 

Mayne,  Dr.,  his  opinion  on  enlarged  ton- 
sils, 352. 

Meatus  externus,  classification  of  its  dis- 
eases, 151 ;  anatomy  of,  158  ;  malforma- 
tions of,  162 ;  diseases  of,  179  ;  abscess 
in,  191  ;  inflammation  of,  193  ;  cutaneous 
diseases  of,  198;  venereal  in,  168;  itch- 
ing of,  198;  ulceration,  199;  morbid 
growth  of  hairs  in,  199;  closure  of,  200; 
tumors  in,  202  ;  condyloma  of,  202  ;  ex- 
ostosis in,  203  ;  polypi  in,  205  ;  malignant 
disease  in,  205. 

Membrana  tympani,  examination  of,  73  ; 
statistics  of  its  diseases,  141-144;  classifi- 
cation of  its  diseases,  152 ;  anatomy  of, 
209 ;  injuries  of,  218  ;  inflammations  of, 
221  ;  abscess  in,  222;  acute  inflammation 
of,  223  ;  strumous  inflammation  of,  260  ; 
morbid  deposits  in,  277;  collapse  of,  278  ; 
artificial  perforation  of,  283 ;  accidental 
perforation  of,  287 ;  rupture  of,  in  strangu- 
lation, 310. 

Membrana  tympani,  artificial,  295. 

Membrane  of  fenestra  rotunda,  300. 

Mercer's  work  on  the  ear,  59. 

Mercurialis,  his  work  on  the  ear,  24. 

Mercury,  its  use  and  mode  of  administra- 
tion, 98-103;  the  bichloride  of,  101 ;  said 
to  cause  deafness,  102. 

Metastasis  in  otorrhoea,  384. 

Meystre,  an  educated  blind  mute,  450. 

Miraculous  cures  of  the  deaf  and  dumb,  414. 

Mitchell,  Dr.,  his  address,  429. 

Mitchell,  James,  blind  and  deaf-dumb,  447. 

Monboddo's  notice  of  Braidv/ood,  421. 

Moore,  Dr.  W.,  his  tract  upon  Irish  Apo- 
thecaries, 47. 

Morbid  deposits  in  membrana  tympani,  277. 

Morgan,  Dr.,  his  case  of  exostosis,  204. 


Morrison,  Dr.,  his  case  of  injury  from  nitric 
acid,  314. 

Mortality  of  the  deaf  and  dumb,  462. 

Morula,  or  button  scurvy  in  meatus,  203. 

Mosaic  law,  reference  to  auricle  in,  165. 

Mucous  lining  of  membrana  tympani,  216  ; 
engorgement  of  tympanum,  261  ;  mem- 
brane of  the  ear,  307 ;  accumulation  in 
middle  ear,  326. 

Mucus  in  tympanum  at  birth,  309. 

Muscles  of  the  auricle,  157 ;  of  the  tympa- 
num, 303. 

Musical  ears,  89. 

Myringitis,  description  of,  221 ;  acute,  223  ; 
subacute,  247  ;  syphilitic,  252  ;  strumous 
260 ;  chronic,  270. 


Navaretti,  an  educated  mute,  416. 

Neglect  of  aural  diseases,  261. 

Neligan's  formula  for  tincture  of  arnica, 
249. 

Nerve,  the  glosso-pharygeal,  301  ;  the  vi- 
dian, 305  ;  the  chorda  tympani,  305 ;  the 
seventh  pair,  355. 

Nerves  of  membrana  tympani,  214  ;  of  tym- 
panum, 304. 

Nervous  deafness,  361 ;  supply  of  the  tym- 
panic lining,  309. 

Neuralgia  of  the  ear,  225,  360. 

Newburg's  tubular  speculum,  70. 

Newland,  Dr.,  his  case  of  otorrhcea,  405. 

New  York  institution,  statistics  of,  429. 

Nitrate  of  silver,  use  and  mode  of  applica- 
tion, 274,  278,  292;  its  effects  on  the 
sense  of  taste,  293;  use  of,  in  otorrhcea, 
388. 

Noise,  loud,  cause  of  injury  to  the  ear,  220, 
221 ;  surrounding,  means  of  improving 
the  hearing,  279,  363. 

Nose,  examination  of,  83  ;  state  of,  in  aural 
disease,  229. 

Nosological  chart  of  aural  diseases,  151- 
153. 

Nun's  school  for  deaf-dumb,  426. 


O'Ferrall,  Dr.,  case  of  fatty  deposit  in  lobes, 
168. 

Opacity  of  membrana  tympani,  274,  365. 

Ophthalmia  with  otitis,  265  ;  a  cause  of 
deaf-dumbness,  265. 

Opprobrium,  causes  of,  in  aural  surgery,  19. 

Orpen,  Dr.,  first  instructor  of  the  deaf  and 
dumb  in  Ireland,  424  ;  his  works,  425. 

Ossicula  auditus,  302;  diseases  of,  345. 

Osteosarcoma  of  ear,  205,  359. 

Otalgia,  225,  360. 

Otic  ganglion,  309. 

Otitis,  242,  316;  rheumatic,  242;  syphili- 
tic, 253  ;  gouty,  259  ;  subacute,  323  ;  in 
connexion  with  ophthalmia,  265 ;  exan- 
thematous,  324 ;  scarlatinous,  fatal  case 
of,  325  ;  with  facial  paralysis,  330. 

Otorrhoea,  374;  gouty,  259;  in  phthisis, 
323 ;  statistics  of,  375 ;  causes  of,  376, 
379;  prejudices  against  healing,  382; 
prognosis  in,  386  ;  character  of  discharge 
in,  387 ;  treatment  of,  388 ;  complications 
of,  392  ;  with  polypus,  393 ;  with  caries. 


INDEX. 


473 


399 ;  with  facial  paralysis,  402 ;  with  ce- 
rebral affections,  403. 
Otoscope,  118. 

Pads,  auricular,  202. 

Pan  for  syringing,  84. 

Paralysis  of  auditory  nerve,  362  ;  facial, 
from  otorrhcea,  369  ;  facial,  from  lesion  of 
nerve,  402;  of  face  from  loud  noise,  220. 

Parturition,  deafness  following,  275. 

Pascal  de  Pietro,  founder  of  the  school  for 
the  deaf  and  dumb  at  Rome,  417. 

Pascha,  Joachim,  an  early  instructor  of  the 
deaf  and  dumb,  415. 

Passavant's  observations  on  typhoid  deaf- 
ness, 269. 

Pathological  Society  of  Dublin,  Proceed- 
ings of,  403. 

Patients,  indifference  of,  to  aural  diseases, 
20. 

Pebbles  in  the  ear,  182. 

Pedius  Quintius,  an  educated  mute  in  the 
time  of  Augustus,  416. 

Peet,  iWr.  H.,  of  New  York,  his  labors,  429. 

Feet,  Mr.  J.  L.,  his  account  of  Meystre, 
450,  451. 

Pemphigus,  gangrenous,  of  auricle,  174. 

Pendola's  division  of  deaf-dumbness,  455. 

Pennant's  notice  of  Braidwood's  academy, 
421. 

Pereira,  an  early  instructor  of  the  deaf  and 
dumb,  418. 

Perforation  of  membrana  tympani,  acci- 
dental, 287;  artificial,  30,  282;  a  new  di- 
agnostic of  290. 

Perilymph,  355. 

Periostitis  of  mastoid  process,  177;  post- 
aural,  244. 

Petit's  proposal  of  Eustachian  catheterism, 
28. 

Petrous  bone,  disease  of,  229. 

Philosophical  transactions,  26,  420. 

Phlebitis  induced  by  otorrhcsa,  406. 

Phthisis,  otorrhcea  in,  323. 

Piercing  the  ear  lobes,  165. 

Pilcher,  Mr.,  his  work  upon  the  ear,  43, 
44 ;  his  classification  of  aural  diseases, 
148 ;  on  inflammation  of  the  membrana 
tympani,  221 ;  on  the  nerves  of  the  tym- 
panum, 304;  on  nervous  diseases  of  the 
ear,  371. 

Polypi  in  meatus,  205  ;  malignant,  206,  207; 
their  characters  and  situation,  393;  their 
treatment,  396. 

Polypus,  nasal,  its  effects  on  hearing,  352. 

Ponce,  Pedro  de,  first  instructor  of  the  deaf 
and  dumb,  416,  463. 

Poor  law,  Irish,  its  provisions  for  the  deaf 
and  dumb,  427. 

Porte-caustic,  description  of,  292. 

Porter,  Dr.,  his  case  of  aural  hemorrhage, 

Portio  dura  nerve,  its  relation  to  the  mem- 
brana tympani,  213  ;  anatomy  of,  355. 

Portio  mollis,  or  auditory  nerve,  355. 

Portugal,  deaf-dumb  in,  417,  433. 

Post-aural  tumors,  175-177. 

Post-febrile  deafness,  328. 

Posture,  peculiarity  of,  in  cerebral  otorrhcea, 
404. 

31 


Potassium,  its  use  and  value,  103. 

Probe,  aural,  289. 

Probes,  Eustachian,  of  Cleland,  26. 

Probing  ears,  87. 

Promontory,  description  of,  300. 

Pruritus  of  external  meatus,  190. 

Prussia,  deaf-dumb  in,  455. 

Pulmonary  disease  consequent  upon  otor- 
rhcea, 405. 

Pulsation  of  membrana  tympani,  216,  291. 

Pump  for  injecting  tympanum,  75-79. 

Purden's,  Dr.,  cases,  439. 

Purkinjie  and  Valentin  on  vibratory  ciliae, 
308. 

Quacks,  cause  of  their  success,  31,  32. 
Queries  for  the  deaf-dumb,  436. 

Race,  effect  of,  in  deaf-dumbness,  436. 

Raphel,  George,  an  early  instructor  of  the 
deaf  and  dumb,  417. 

Registry  of  ear  cases,  120-139. 

Rein's  hearing  trumpets,  411. 

Relaxation  of  membrana  tympani,  278. 

Review,  British  and  Foreign  Medical,  its 
notices  of  aural  surgery,  41. 

Rheumatic  otitis,  242,  333. 

Richmond  pathological  collection,  399. 

Rigors  in  otitis,  321 ;  a  symptom  in  cere- 
bral otorrhcea,  404. 

Rivinus,  Dr.,  his  translation  of  Larrey's 
work,  59  ;  on  the  aperture  of  the  mem- 
brana tympani,  214. 

Roget,  Dr.,  his  article  on  the  deaf  and 
dumb,  423. 

Rome,  deaf  and  dumb  school  at,  417. 

Rose,  Madame  de  Saint,  an  early  instruc- 
tor of  the  deaf  and  dumb,  418. 

Roslet's  papers  on  the  ear,  30. 

Roux,  Dr.,  his  case  of  facial  paralysis,  333. 

Rupture  of  membrana  tympani,  219 ;  in 
strangulation,  310. 


St.  Mark's  Hospital,  clinique,  18  ;  statistics 
of  ear  diseases  at,  104. 

Salivation,  excessive,  101. 

Santorini,  fissures  of,  157. 

Saunders's  work  upon  the  ear,  35  ;  his  opi- 
nions and  writings,  348  ;  on  nervous  deaf- 
ness, 368. 

Sauveur's  investigations  on  deaf-dumbness, 
325,  433,  440;  statistics  of  muteism,  432. 

Scarlatina,  a  cause  of  otorrhcea,  321,  325; 
otitis  in,  324  ;  a  cause  of  acquired  deaf- 
dumbness,  324. 

Scharpnell's  membrana  flaccida,  211. 

Schmalz's  writings  upon  the  ear,  43  ;  figures 
of  malformed  auricle,  161 ;  exostosis, 
205  ;  divisions  of  nervous  deafness,  366  ; 
his  work  on  the  deaf  and  dumb,  417,  432. 

Schools  for  the  deaf  and  dumb,  430 ;  Swiss, 
432;  Irish,  435  ;  American,  435. 

Scirrhous  degeneration  of  auricle,  Kramer 
on,  170. 

Scissors  for  removing  polypi,  396. 

Scotland,  instruction  of  deaf  mutes  in,  421, 
430. 

Scott,  Dr.,  of  Exeter,  his  work  on  the  deaf 
and  dumb,  427. 


474 


INDEX. 


Scott,  Sir  Walter,  his  opinion  of  Duncan 
Campbell,  420  ;  his  Fenella,  462. 

Scrofula  among  deaf-dumb,  462. 

Seamen,  liability  of,  to  aural  diseases,  340. 

Sedatives  in  aural  diseases,  231. 

Segalas,  his  lamp  for  examining  the  ear  as- 
cribed to  Mr.  Avery,  70.  See  Medical 
Times  and  Gazette  for  25th  Dec,  1852. 

Seguin,  M.  E.,  his  vi'ork  on  Pereira,  418. 

Senses,  development  of,  434. 

Serous  fluid,  evacuation  of,  in  fracture  of 
the  skull,  315. 

Sex  and  age  in  aural  diseases,  statistics  of, 
119. 

Shakspeare  on  aural  idiosyncrasy,  361. 

Sherwood's,  Mrs.,  Theophilus,  427. 

Short  hearing,  29. 

Sibscota's  writings  on  the  deaf  and  dumb, 
420. 

Sicard,  the  Abbe,  418. 

Signing,  methods  of,  416,  425,  431. 

Sims,  Dr.,  his  papers  on  the  ear,  30. 

Skelly,  W.  N.,  his  labors  for  the  deaf  and 
dumb  in  Ireland,  426. 

Slaves,  deaf-dumb,  435. 

Sloan's,  Sir  H,.  case  of  deaf,  dumb,  and 
blind,  450. 

Smith,  N.  R.,  his  translation  of  Saissy,  59. 

Smith,  Dr.  "R.,  his  aural  dissections,  400 ; 
cases  of  otorrhoea,  405. 

Smoking  in  diseases  of  the  ear,  252. 

Snare  for  removing  polypi,  397. 

Soemmering's  book  and  plates  of  the  ear, 
30,  215. 

Sounds  heard  in  the  tympanum  by  auscul- 
tation, 74,  80. 

South  Sea  islanders'  mode  of  ornamenting 
the  ear,  167. 

Spain,  deaf-dumbness  in,  430,  433. 

Spanish  writers  on  deaf-dumbness,  415. 

Spatula,  aural,  184. 

Speculum  of  Fabricius,  24;  the  tubular, 
70-72. 

Speech,  loss  of,  in  fever,  327 ;  first  develop- 
ment of,  434. 

Speranza,  M.,  his  case  of  aural  injury, 
357. 

Splitting  ears,  a  mode  of  punishment,  164. 

Spurzheim's  account  of  James  Mitchell, 
448. 

Stapedius  muscle,  304. 

Stapes,  description  of,  303. 

Statistics  of  aural  diseases,  105,  115-118; 
Schools,  430;  Swiss,  432;  Irish,  435; 
American,  435;  of  deaf-dumbness,  gene- 
ral, 432 ;  in  Ireland,  426. 

Stephenson,  Mr.,  his  work  on  the  ear,  37. 

Stethoscope,  use  of,  in  aural  examinations, 
75. 

Stewart's,  Dugald,  account  of  James 
Mitchell,  447. 

Stilettes,  82,  348. 

Stockholm,  institution  for  the  deaf  and 
dumb  at,  418. 

Stokes,  Dr.  Whitley,  his  description  of 
pemphigus,  174. 

Stokes,  Dr.  William,  his  cases,  244,  405. 

Stomach  deafness,  18,  344 ;  Mr.  Yearsley 
upon,  46,  47. 

Strabane  school  for  deaf-dumb,  426. 


Strangulation,  a  cause  of  aural  hemorrhage, 

310. 
Stricture  of  Eustachian  tube,  348. 
Structure  of  membrana  tympani,  213. 
Strumous  myringitis,  260. 
Sullivan  Margaret,  deaf,  dumb,  and  blind, 

465. 
Superstitions  regarding  auricle,    165 ;    on 

muteism,  461. 
Surgery,    Cyclopeedia  of  Practical,   article 

Ear,  45. 
Swan,  Mr.,  his  anatomy  of  the  ear,  40;  on 

nervous  deafness,  371. 
Swift,  Dean,  his  deafness,  373. 
Switzerland,  deaf-dumbness  in,  432,  440. 
Syme,  Mr.,  his  case  of  tumor  of  the  lobe, 

167  ;  case  of  aural  hemorrhage,  326. 
Sympathetic  nerve,  its  connexion  with  the 

tympanum,  309. 
Synovial  tumors  in  auricle,  168, 
Syphilitic  myringitis,  252. 
Syringe,  aural,  85. 
Syringing,  mode  of,  84,  188. 
Syringitis,  347. 

Table  of  ear  diseases,  108,  109. 

Temmerman's,  Anna,  deaf,  dumb,  and 
bhnd,  448. 

Temporal  bone,  anatomy  of,  154;  caries  of, 
400. 

Tensor  tympani  muscle,  303. 

Thickening  of  membrana  tympani,  273. 

Thompson,  Dr.,  his  cases  of  malformation 
of  the  ear,  161  ;  opinions  on  muteism, 
161. 

Thornton's  work  on  the  ear,  37. 

Throat,  examination  of,  88 ;  affections  of, 
in  aural  disease,  229;  mode  of  applying 
caustic  to,  262. 

Throat  deafness,  351. 

Thurnham,  Dr.,  his  opinion  of  inflamma- 
tion of  the  auricles  in  the  insane,  169. 

Tinnitus  aurium,  its  value  and  characteris-  ■ 
tics,  92-94. 

Tinnitus  aurium,  92,  145,  359. 

Tod's  work  upon  the  ear,  40. 

Tongue,  peculiarities  of,  in  muteism,  438, 
441;  tongue-tie,  434;  malformations  of, 
439. 

Tonsils,  their  position  and  pathology,  307  ; 
enlargement  of,  a  supposed  cause  of  deaf- 
ness, 351. 

Townsend,  Dr.  J.,  originator  of  the  Kent 
Road  Asylum,  422. 

Toynbee,  Mr.,  his  pathological  investiga- 
tion of  the  ear,  49,  116-118;  on  auro- 
cerebral  diseases,  197 ;  on  exostosis, 
203 ;  on  the  structure  of  the  membrana 
tympani,  214  ;  on  the  deafness  of  old  age, 
260  ;  artificial  membrana  tympani,  298 ; 
457 ;  the  muscles  of  the  tympanum,  301 ; 
305;  stricture  of  Eustachian  tube,  349; 
polypi,  395  ;  on  cerebral  diseases,  403. 

Tragus.     See  Auricle. 

Travers,  Dr.,  on  the  ancient  opinions  re- 
garding deafness  in  fever,  330. 

Travers,  Mr.,  on  malignant  fungus  of  ear, 
359. 

Trials  of  deaf-dumb,  463. 

Trumpets,  hearing,  410. 


INDEX. 


475 


Tscharner's  statistics  of  ear  diseases,  115. 

Tubercular  deposit  in  internal  ear,  359. 

Tubes,  aural,  their  value,  201. 

Tumors  of  the  auricle,  166,  207  ;  fibrous  of 
lobe,  167  ;  synovial,  in  auricle,  168  ;  of 
mastoid  region,  175  ;  of  meatus,  203. 

Turnbull,  Dr.  A.,  his  miracles,  54;  his 
treatise  on  the  ear,  55. 

Twigg,  Dr.,  his  case  of  deaf,  dumb,  and 
blind,  454. 

Twin  mutes,  443. 

Tympanic  plexus  of  nerves,  301,  309. 

Tympanitis,  222. 

Tympanum,  anatomy  and  diseases  of,  299  ; 
statistics  of  its  diseases,  144  ;  injuries  of, 
310;  hemorrhage  from,  310;  inflamma- 
tions of,  316  ;  chronic  inflammation  of  its 
mucous  lining,  337  ;  morbid  growths  and 
deposits  in,  346 ;  malignant  disease  of, 
346. 

Typhoid  otitis,  268. 


Ulceration  of  meatus,  199 ;   of  merabrana 

tympani,  290. 
Ulster  institution  for  deaf-dumb,  426. 


Valleroux's  work  upon  the  ear,  40. 

Valsalva's  book  on  the  ear,  30. 

Vanin,  an  early  instructor  of  the  deaf  and 

dumb,  418, 
Vapor  douche  in  nervous  deafness,  369. 
Vapors,  medicated,  introduction  of,  into  the 

tympanum,  40,  84. 
Venereal  affections  of  the  ear,  196,  198. 
Vering,  on  gouty  otitis,  259. 
Vestibule,  anatomy  of,  354. 
Vibration,   insensibility  of  deaf-dumb   to, 

446. 
Vibrissas,  disease  of,  199. 
Vidian  nerve,  305. 
Vienna,  school  at,  446. 
Voice,  its  character  in  the  deaf,  89. 


Vomiting,  from  foreign  body  in  meatus, 
190. 

Wakley,  Mr.  T.  on  glycerine,  52. 
Wallar,  R.,  his  writings  on  the  deaf  and 

dumb,  420. 
Wallis,  Dr.  J.,  first   English  instructor  of 

the  deaf  and  dumb,  419. 
Walpole's  Reminiscences,  their  allusion  to 

Cheselden,  33. 
Walsh's,  Dr.,  case  of  dumbness,  439. 
Warden's,  Dr.,  writings  on  the  ear,  59. 
Wathan,  Eustachian  catheterism  by,  27. 
Watson,  Dr.  J.,  his  instruction  of  the  deaf 

and  dumb,  422. 
Wax  of  the  ear,    160  ;   collections  of,   in 

meatus,  184.     See  Cerumenous  glands. 
Webster's  work  on  the  ear,  38. 
Weiss,  his  speculum,  68. 
Weld,  Mr.  L.,  429. 
Wild,   Jac,  an  instructor  of  the  deaf  and 

dumb,  417. 
Williams,  his  works  on  the  ear,  37,  44  ;  on 

inflammation  of  the  membrana  tympani, 

222 ;   his    anatomy  of  the   ear,  303 ;  on 

otorrhoea,  385  ;  on  muteism,  461. 
Willis,  on  relaxation  of  membrana  tympani, 

279. 
Wishart,  Mr.,  on  malignant  fungus  of  ear, 

359. 
Wolff,  on  aural  fumigations,  370. 
Woodroffe's  account  of  Julia  Brace,  448. 
Wounds  of  auricle,  164  ;  of  external  meatus, 

179. 
Wright,  Mr.  W.,  his  observations  on  dis- 
eases of  the  ear,  37. 
Wright's,  Miss,  school  at  Moneymore,  426. 

Yearsley,  Mr.,  his  writings,  47 ;  his  per- 
forator, 285  ;  on  artificial  membrana 
tympani,  47,  296 ;  on  throat  deafness, 
351. 

Zeucher,  Dr.,  his  papers  on  the  ear,  30. 


THE    END. 


BLANCHAE.D   &   LEA'S    MEDICAL 


QUAKTERLY  SUMMARY, 

being  a  very  full  and  complete  abstract,  methodically  arrang-ed,  of  the    j  »• 

IMPROVEMENTS  AND  DISCOVERIES  IN  THE  MEDICAL  SCIENCES. 

This  department  of  the  Journal,  so  Important  to  the  practising  physician,  is  the  object  of  especial 
care  on  the  part  of  the  editor.  It  is  classified  and  arranged  under  different  heads,  thus  facilitating 
the  researches  of  the  reader  in  pursuit  of  particular  subjects,  and  will  be  found  to  present  a  very 
full  and  accurate  digest  of  all  observations,  discoveries,  and  inventions  recorded  in  every  branch  of 
medical  science.  The  very  extensive  arrangements  of  the  publishers  are  such  as  to  afford  to  the 
editor  complete  materials  for  this  purpose,  as  he  not  only  regularly  receives 

ALL  THE  AMERICAN  MEDICAL  AND  SCIENTIFIC  PERIODICALS, 

but  also  twenty  or  thirty  of  the  more  important  Journals  issued  in  Great  Britain  and  on  the  Conti- 
nent, thus  enalDling  him  to  present  in  a  convenient  compass  a  thorough  and  complete  abstract  of 
everythmg  interesting  or  important  to  the  physician  occurring  in  any  part  of  the  civilized  world. 

An  evidence  of  the  success  which  has  attended  these  efforts  may  be  found  in  the  constant  and 
steady  increase  in  the  subscription  li^^t,  which  renders  it  advisable  for  gentlemen  desiring  the 
Journal,  to  make  known  their  wishes  at  an  early  day,  in  order  to  secure  a  year's  set  with  certainty, 
the  publishers  having  frequently  been  unable  to  supply  copies  when  ordered  late  in  the  year.  To 
their  old  subscribers,  many  of  whom  have  been  on  their  list  for  twenty  or  thirty  years,  the  publish- 
ers leel  that  no  promises  are  necessary;  but  those  who  may  desire  for  the  first  time  to  subscribe, 
can  rest  assured  that  no  exertion  will  be  spared  to  maintain  the  Journal  in  the  high  position  which 
it  has  occupied  for  so  long  a  period. 


By  reference  to  the  terms  it  will  be  seen  that,  in  addition  to  this  large  amount  of  valuable  and 
practical  information  on  every  branch  of  medical  science,  the  subscriber,  by  paying  in  advance, 
becomes  entitled,  without  further  charge,  to 

THE  MEDICAL  NEWS  AND  LIBRARY. 

a  monthly  periodical  of  thirty-two  large  octavo  pages.  Its  "News  Department"  presents  the 
current  information  of  the  day,  while  the  "Library  Department"  is  devoted  to  presenting  stand- 
ard works  on  various  branches  of  medicine.  Within  a  few  years,  subscribers  have  thus  received, 
without  expense,  the  following  works  which  have  passed  through  its  columns  : — 

WATSON'S  LECTURES  ON  THE  PRACTICE  OF  PHYSIC. 

BRODIE'S  CLINICAL  LECTURES  ON  SURGERY. 

TODD  AND  BOWMAN'S  PHYSIOLOGICAL  ANATOMY  AND  PHYSIOLOGY  OF  MAN. 
724  pages,  with  numerous  wood-cuts,  being  all  that  has  yet  appeared  in  England. 

WEST'S  LECTURES  ON  THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 

MALGAIGNE'S  OPERATIVE  SURGERY,  with  wood-cuts,  and 

SIMON'S  LECTURES  ON  GENERAL  PATHOLOGY. 

While  the  year  1854,  presents 

BENNETT  ON   PULMONARY  TUBERCULOSIS, 

BEAUTIFULLY  ILLUSTRATED   ON   WOOD. 

1^°  Subscribers  for  1853,  who  do  not  possess  the  commencement  of  Todd  and  Bowman's 
Physiology,  can  obtain  it,  in  a  handsome  octavo  volume,  of  552  pages,  with  over  150  illustrations, 
by  mail,  free  of  postage,  on  a  remittance  of  $2  50  to  the  publishers. 


It  will  thus  be  seen  that  for  the  small  sum  of  FIVE  DOLLARS,  paid  in  advance,  the  subscriber 
will  obtain  a  Quarterly  and  a  Monthly  periodical, 

EMBRACING  ABOUT  FIFTEEN  HUNDRED  LARGE  OCTAVO  PAGES 

Evailed  to  any  part  of  the  United  States,  free  of  postage. 

These  very  favorable  terms  are  now  presented  by  the  publishers  with  the  view  of  removing  all 
difficulties  and  objections  to  a  full  and  extended  circulation  of  the  Medical  Journal  to  the  office  of 
every  member  of  the  profession  throughout  the  United  Slates.  The  rapid  extension  of  mail  facili- 
ties, will  now  place  the  numbers  before  subscribers  with  a  certainty  and  dispatch  not  heretofore 
attainable;  while  by  the  system  now  proposed,  every  subscriber  throughout  the  Union  is  placed 
upon  an  equal  footing,  at  the  very  reasonable  price  of  Five  Dollars  for  two  periodicals,  without 
further  expense. 

TJaose  subscribers  who  do  not  pay  in  advance  will  bear  in  mind  that  their  subscription  of  Five 
Dollars  will  entitle  them  to  the  Journal  only,  without  the  News,  and  that  they  will  be  at  the  expense 
of  their  own  postage  on  the  receipt  of  each  number.  The  advantage  of  a  remittance  when  order- 
ing the  Journal  will  thus  be  appansnt. 

As  the  Medical  News  and  Library  is  in  no  case  sent  without  advance  payment,  its  subscribers 
will  always  receive  it  free  of  postage. 

It  should  also  be  borne  in  mind  that  the  publisJiers  wiU  now  take  the  risk  of  remittances  by  mail, 
only  requiring,  in  eases  of  loss,  a  certificate  from  the  subscriber's  Postmaster,  that  the  money  was 
duly  mailed  and  forwarded 

1^^  Funds  at  par  at  the  subscribe-r's  place  of  residence  received  in  payment  of  subscriptions. 

Address,  BLANCHARD  &  LEA,  Philadelphia. 


AND    SCIENTIFIC    PUBLICATIONS. 


ANALYTICAL    COMPENDIUM 
OF  MEDICAL  SCIENCE,  containing  Anatomy,  Physiology,  Surgery,  Midwifery 

Ctiemistry,  Materia  Medica,  Therapeutics,  and  Practice  of  Medicine.  By  John  Neill,  M.  d/ 
and  F.  G.  Smith,  M.  D.  Second  and  enlarged  edition,  one  thick  volume  royal  12mo.'of  over 
1000  pages,  with  350  illustrations,     l^^  See  Neill. 


ABEL   (F.    A.),    F.  C.  S. 

Professor  of  Chemistry  in  the  Royal  Military  Academy,  Woolwich. 

'  a:«d 

C.    L.    BLOXAM, 

Formerly  First  Assistant  at  the  Royal  College  of  Chemistry. 

HANDBOOK  OF  CHEMISTRY,  Theoretical,  Practical,  and  Technical,  with  a 
Recommendatory  Preface  by  Dr.  Hof.\iann.  In  one  large  octavo  volume  of  662  pa'^es  with 
illustrations.     (Now  Ready.) 

There  was  still  wanting  some  bonk  which  should  ;  who  resolves  to  pursue  for  himself  a  steady  search 

aid  the   young  analytical  chemist   through  all    the  into  tlie  cliem  cul  mysteries  of  creation.     For  such 

phases  of  the  science.    The  "  Handbook"  of  Messrs.  a  student  the  'Handbook'  will  prove  an  excellent 

Abel  and  Bloxam  appears  to  supply  that  want.     As  guide,  since  he  will  find  in  it,  n.^t  merely  the  most 

Dr.  Hofmann  says  in  his  brief  Preface,  ''  The  pre-  approved    modes   of   analytical    investigation,   but 

sent  volume  is  a  synopsis  of  their  (the  authors')  ex-  descriptions  of  the  apparatus  necessary,  with  such 

perience  in  laboratory  teaching  ;  it  gives  the  neces-  manipulatory  details  as  rendered  Faraday's  '  Che- 

sary  instruction  in  chemical  manipulation,  a  concise  mical  Manipulations'  so  valuahle  at  the  time  of  its 

account  of  general  chemistry  as  far  as  it  is  involved  publication.     Beyond   this,    the   importance  of  the 

in  the  operations  of  the  laboratory,  and  lastly,  quali-  work  is  mcreased  by  the  introduction  of  much  of  the 

tative  and  quantitative  analysis.     It  must  be  under-  technical   chemistry   of  the   manufactory."— ji«/ie- 

stood  that  this  is  a  work  fitted  for  the  earnest  student,  na:u?n. 


ASHWELL   (SAMUEL),   M.D. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  PECULIAR  TO  WOMEN. 

Illustrated  by  Cases  derived  froin  Hospital  and  Private  Practice.     With  Additions  by  Paul  Beck 
GoDDAED,  M.  D.     Second  American  edition.     In  one  octavo  volume,  of  520  pages. 


ARNOTT   (NEILL),  M.  D. 

ELEMENTS  OF  PHYSICS;  or  Natural  Philosophy,  General  and  Medical. 
Written  for  universal  use,  in  plain  or  non-technical  language.  A  new  edition,  by  Isaac  Hays 
M.  D.     Complete  in  one  octavo  volume,  of  484  pages,  with  about  two  hundred  illustrations, 

BENNETT   (J.    HUGHES),    M.D.,    F.  R.  S.  E., 

Professor  of  Clinical  Medicine  in  the  University  of  Edinburgh,  iScc. 

THE  PATHOLOGY  AND  TREATMENT  OF  PULMONARY  TUBERCU- 
LOSIS, and  on  the  Local  Medication  of  Pharyngeal  and  Laryngeal  Diseases  frequently  mistaken 
for  or  associated  with.  Phthisis.     In  one  handsome  octavo  volume,  with  beautiful  wood-cuts. 

Now  publishing  in  the  "Medical  News  and  Library"  for  1854,  and  furnished  gratis  to  advance- 
paying  subscribers  to  the  American  Journal  of  the  Medical  Sciences. 


How  it  may  be  most  effectually  carried  into  prac- 
tice, our  readers  will  learn  from  L)r.  Bennett's  pages, 
especially  from  the  histories  of  the  valuable  and  in- 
teresting cases  which  he  records.  Indeed,  if  the  au- 
thor had  only  reported  these  cases  he  would  have 
benefited  his  profession,  and  deserved  our  thanks.  As 
it  is,  how^ever,  his  w^hole  volume  is  so  replete  with 
valuable  matter,  that  we  feel  bound  to  recommend 
our  readers,  one  and  all,  to  peruse  it. — Land.  Lancet. 


The  elegant  little  treatise  before  us  shows  how 
faithfully  and  intelligently  these  investigations  have 
been  pursued,  and  how  successfully  the  author's 
studies  have  resulted  in  clearing  up  some  of  the  most 
doubtful  points  and  conflicting  doctrines  hitherto 
entertained  in  reference  to  the  history  and  treatment 
of  pulmonary  tuberculosis.— iV.  Y.  Journal  of  Medi- 
cal and  Collateral  Science,  March,  1854. 


BENNETT   (HENRY),  M.  D. 
A  PRACTICAL   TREATISE   ON  INFLAMMATION  OF  THE  UTERUS 

ITS  CERVIX  AND   APPENDAGES,  and  on  its  connection  with  Uterine  Disease.     Fourth 

American,  from  the  third  and  revised  London  edition.     In  one  neat  octavo  volume,  of  430  pao-es 

with  wood-cuts.     (Now  Ready.) 

This  edition  will  be  found  materially  improved  over  its  predecessors,  the  author  having  carefully 
revised  it,  and  made  considerable  additions,  amounting  to  about  seventy-live  pages. 

This  edition  has  been  carefully  revised  and  altered, 
and  various  additions  have  been  made,  which  render 
it  more  complete,  and,  if  possible,  more  worthy  of 


the  high  appreciatitm  in  which  it  is  held  by  the 
medical  prof^ession  throughout  the  world.  A  copy 
should  be  in  the  possession  of  every  physician. — 
Charleston  Med.  Journal  and  Review,  March,  1854. 
We  are  firmly  of  opinion  that  in  proportion  as  a 
knowledge  of  uterine  diseases  becomes  more  appre- 
c.ated.  this  work  will  be  proportionably  established 
as  a  text-book  in  the  profession. — The  Lancet. 

When,  a  few  years  back,  the  first  edition  of  the 
present  work  was  published,  the  subject  was  one 
almost  entirely  unknown  to  the  obstetrical  celebrities 
of  the  day;  and  even  now  we  have  reason  to  know 


that  the  bulk  of  the  profession  are  not  fully  alive  to 
the  importance  and  frequency  of  the  disease  of  which 
it  takes  cognizance.  The  present  edition  is  so  much 
enlarged,  altered,  and  improved,  that  it  can  scarcely 
be  considered  the  same  work.— Dr.  Eanlcing's  Al>- 
stract. 


Few  works  issue  from  the  medical  press  which 
are  at  once  original  and  sound  in  doctrine  ;  but  such, 
we  feel  assured,  is  the  admirable  treatise  now  before 
us.  The  important  practical  precepts  which  the 
author  inculcates  are  all  rigidly  deduced  from  facts. 
.  .  .  Every  page  of  the  book  is  good,  and  eminently 
practical.  .  .  .  So  far  as  ■we  kno^v  and  believe,  it  is 
the  best  work  on  the  subject  of  which  it  treats. — 
Monthly  Journal  of  Medical  Science. 


BLANCHARD   &   LEA'S   MEDICAL 


BEALE  (LIONEL   JOH  N),  M .  R.  C.  S.,  fitc. 
THE   LAWS   OF    HEALTH   IN   RELATION   TO    MIND    AND   BODY. 

A  Series  of  Letters  from  an  old  Practitioner  to  a  Patient.     In  one  handsome  volume,  royal  12mo., 
extra  cloth. 


BILLING    (ARCHIBALD),  M.  D. 
THE  PRINCIPLES  OP  MEDICINE.     Second  American,  from  the  Fifth  and 

Improved  London  edition.    In  one  handsome  octavo  volume,  extra  cloth,  250  pages. 


BLAKISTON    (PEYTON),  M.  D,,  F.  R.  S.,  &c. 
PRACTICAL    OBSERVATIONS    ON    CERTAIN    DISEASES    OF    THE 

CHEST,  and  on  the  Principles  of  Auscultation.    In  one  volume.  8vo.,  pp.  384. 


BURROWS    (GEORGE),  M.  D. 

ON  DISORDERS  OF  THE  CEREBRAL  CIRCULATION,  and  on  the  Con- 
nection between  the  Affections  of  tlie  Brain  and  Diseases  of  the  Heart.  In  one  8vo.  vol.,  with 
colored  plates,  pp.  216. 

BUDD  (GEORGE),  M .  D.,  F.  R.  S., 

Professor  of  Medicine,  in  King's  College,  London. 

ON   DISEASES   OP   THE   LIVER.     Second  American,  from  the  second  and 

enlarged  London  edition.     In  one  very  handsome  octavo  volume,  with  four  beautifully  colored 
plates,  and  numerous  wood-cuts,     pp.468.    New  edition.     [Just  Issued.) 

The  reputation  which  this  work  has  obtained  as  a  full  and  practical  treatise  on  an  important  class 
of  diseases  will  not  be  diminished  by  this  improved  and  enlarged  edition.  It  has  been  carefully  and 
thoroughly  revised  by  the  author ;  the  number  of  plates  has  been  increased,  and  the  style  of  its  me- 
chanical execution  will  be  found  materially  improved. 


The  full  digest  we  have  given  of  the  new  matter 
introduced  into  ihe  present  volume,  is  evidence  of 
the  value  we  place  on  it.  The  fact  that  the  profes- 
sion has  required  a  second  edition  of  a  monograph 
such  as  that  before  ns,  hears  honorable  testimony 
to  its   usefulnes.s.  ,  For   many  years.  Dr.   Budd's 


work  must  be  the  authority  of  the  great  mass  cd 
British  practitioners  on  the  hepatic  diseases  ;  and  it 
is  satisfactory  that  the  subject  has  been  taken  up  by 
so  able  and  experienced  a  physician. — British  and 
Foreign  Medico-Chirxirgical  Review. 


BUCKLER  (T.  H.),  M.  D., 

Formerly  Physician  to  the  Baltimore  Almshouse  Infirmary,  &c. 

ON  THE  ETIOLOGY,  PATHOLOGY,  AND  TREATMENT  OF   FIBRO- 

BKONCHITIS  AND  RHEUMATIC  PNEUMONIA.     In  one  handsome  octavo  volume,  extra 
cloth.     (Now  Ready.) 


The  concluding  chapter  on  Treatment  is  full  of 
sound  practical  suggestions,  which  make  this  emi- 
nently a  book  to  be  prized  by  the  "  working  doctor" 


rather  than  the  mere  closet  student. — JV.  /.  Medical 
Reporter,  March,  1854. 


BLOOD  AND   URINE  (MANUALS  ON). 
BY  JOHN  WILLIAM   GRIFFITH,   G.  OWEN  REESE,   AND  ALFRED 

MARKWICK.     One  thick  volume,  royal  12mo.,  extra  cloth,  with  plates,    pp.  460. 

BRODIE  (SIR  BENJAMIN   C),  M.  D,,  8i.c. 
CLINICAL  LECTURES  ON  SURGERY.     1  vol.  8vo.,  cloth.     850  pp. 

BY    THE   SAME    AUTHOR. 

SELECT  SURGICAL  WORKS,  1  vol.  8vo.  leather,  containing  Clinical  Lectures 

on  Surgery,  Diseases  of  the  Joints,  and  Diseases  of  the  Urinary  Organs. 


BIRD  (GOLDING),  A.  M.,  M.  D.,  &,c. 
URINARY     DEPOSITS:     THEIR     DIAGNOSIS,    PATHOLOGY,    AND 

THERAPEUTICAL  INDICATIONS.    A  new  and  enlarged  American,  from  the  last  improved 
London  edition.    With  over  sixty  illustrations.     In  one  royal  12ino.  volume,  extra  cloih. 


The  new  edition  of  Dr.  Bird's  work,  though  not 
increased  in  size,  has  been  greatly  modified,  and 
mueh  of  it  rewritten.  It  now  presents,  in  a  com- 
pendious form,  the  gist  of  all  that  is  known  and  re- 
liable in  this  department.  From  its  terse  style  and 
convenient  size,  it  is  particularly  applicable  to  the 
student,  to  whom  we  cordially  commend  it. —  The 
Medical  Examiner. 

It  can  scarcely  be  necessary  for  us  to  say  anything 
Oif  the  merits  of  this  well-known  Treatise,  which  so 
adiKtrably  brings  into  practical  application  the  re- 


sults of  those  microscopical  and  chemical  researches 
regarding  the  physiology  and  pathology  of  the  uri- 
nary secretion,  wliich  have  contributed  so  much  to 
the  increase  of  our  diagnpstie  powers,  and  to  tlie 
extension  and  satisfactory  employment  of  our  thera- 
peutic resources.  ]n  the  preparation  of  tliis  new 
edition  of  his  work,  it  is  obvious  that  Dr.  Golding 
Bird  has  spared  no  pains  to  render  it  a  faithful  repre- 
sentation of  the  present  state  of  scientific  knowledge 
on  the  subject  it  embraces.-  The  British  and  Foreign 
Medico-C hirurgical  Review. 


BY   THE  SAME   AUTHOR. 


ELEMENTS  OF  NATURAL  PHILOSOPHY;  being  an  Experimental  Intro- 
duction to  the  Physical  Sciences.  Illustrated  with  nearly  four  hundred  wood-cuts.  From  the 
third  London  edition.     In  one  neat  volume,  royal  12mo.    pp.  402. 


AND    SCIENTIFIC    PUBLICATIONS. 


BARTLETT  (ELISHA),  M.  D., 

Professor  of  Materia  Medica  and  Medical  Jurisprudence  in  the  College  of  Physicians  and 
Surgeons,  New  York. 

THE   HISTORY,  DIAGNOSIS,  AND  TREATMENT  OF  THE  FEVERS 

OF  THE  UNITED  STATES.     Third  edition,  revised  and  improved.     In  one  octavo  volume, 

of  six  hundred  pages,  beautifully  printed,  and  strongly  bound. 

In  preparing  a  new  edition  of  this  standard  work,  the  author  has  availed  himself  of  such  obser- 
vations and  investigations  as  have  appeared  since  the  publication  of  his  last  revision,  and  he  has 
endeavored  in  every  way  to  render  it  worthy  of  a  continuance  of  the  very  marked  favor  with  which 
it  has  been  hitherto  received. 

Of  the  value  and  importance  of  such  a  work,  it  is 
needless  here  to  speak  ;  the  profession  of  the  United 
States  owe  much  to  the  author  for  the  very  able 
volume  which  he  has  presented  to  them,  and  for  the 
careful  and  judicious  manner  in  which  he  has  exe- 
cuted his  task.  No  one  volume  with  which  we  are 
acquainted  contains  so  complete  a  history  of  our 
fevers  as  this.  To  Dr.  Bartiett  we  owe  our  best 
thanks  for  the  very  able  volume  he  has  given  us,  as 
embodying  certainly  the  most  complete,  methodical, 
and  satisfactory  account  of  our  fevers  anywhere  to 
be  met  with.-^TAe  Charleston  Med.  Journal  and 
Review. 


The  masterly  and  elegant  treatise,  by  Dr.  Bartiett 
is  invaluable  to  the  American  student  and  practi- 
tioner.— Dr.  Holmes- s  Report  to  the  Nat.  Med.  Asso- 
ciation. 

AVe  regard  it,  from  the  examination  we  have  made 
of  it,  the  best  work  on  fevers  extant  in  our  language, 
and  as  such  cordially  recommend  it  to  the  medical 
public. — St.  Louis  Medical  and  Surgical  Journal. 

Take  it  altogether,  it  is  the  most  complete  history 
of  our  fevers  which  has  yet  been  published,  and 
every  practitioner  should  avail  himself  of  its  con- 
tents.— The  Western  Lancet. 


BOWMAN  (JOHN    E.),  M.D. 
PRACTICAL   HANDBOOK   OF    MEDICAL    CHEMISTRY.     In  one  neat 

volume,  royal  12mo.,  with  numerous  illustrations,     pp.  288. 

BY  THE  SAME  AUTHOR. 

INTRODUCTION    TO    PRACTICAL    CHEMISTRY,    INCLUDING   ANA- 

LYSIS.    With  numerous  illustrations.     la  one  neat  volume,  royal  12mo.    pp.  350. 


BARLOW   (GEORGE  H.),   M.D. 
A  MANUAL  OF  THE  PRINCIPLES  AND  PRACTICE  OF  MEDICINE. 

lu  one  oclavo  volume.     {Preparing.) 

CYCLOP/EDIA    OF    PRACTICAL    MEDICINE. 

Edited  by  Dunglison,  Forbes,  Tweedie,  and  Conolly,  in  four  large  octavo 
volumes,  strongly  bound.     B^"  See  Dunglison. 


COLOMBAT  DE  LMSERE. 
A  TREATISE   ON   THE    DISEASES    OF   FEMALES,  and  on  the  Special 

Hygiene  of  their  Sex.  Translated,  with  many  Notes  and  Additions,  by  C.  D.  JMeigs,  M.  D. 
Second  edition,  revised  and  improved.  In  one  large  volume,  octavo,  with  numerous  wood-cuts, 
pp.  720. 

The  treatise  of  M.  Colombat  is  a  learned  and  la-  |  M.  Colombat  De  L'lsere  has  not  consecrated  ten 
borious  commentary  on  these  diseases,  indicating  years  of  studious  toil  and  research  to  the  frailer  sex 
very  considerable  research,  great  accuracy  of  judg-  ,  in  vain;  and  although  we  regret  to  hear  it  is  at  the 
ment,  and  no  inconsiderable  personal  experience,  expense  of  health,  he  has  imposed  a  debt  of  gratitude 
^Vith  the  copious  notes  and  additions  of  its  experi-  as  well  upon  the  profession,  as  upon  the  mothers  and 
enced  and  very  erudite  translator  and  editor,  Dr.  daughters  of  beautiful  France,  which  that  gallant 
Meigs,  it  presents,  probably,  one  of  the  most  com-  nation  knows  best  how  to  acknowledge. — New  Or- 
plete  and  comprehensive  works  on  the  subject  we  leans  Medical  Journal . 
possess. — American  Med.  Journal.  j 


COPLAND  (JAMES),  M.  D.,  F.  R.  S.,  &c. 
OF   THE   CAUSES,  NATURE,   AND  TREATMENT   OF    PALSY    AND 

APOPLEXY,  and  of  the  Forms,  Seats,  Complications,  and  Morbid  Relations  of  Paralytic  and 
Apoplectic  Diseases.     In  one  volume,  royal  12mo.,  extra  cloth,    pp.  326. 


CHAPMAN  (PROFESSOR  N.),  M.  D.,  <SiC. 
LECTURES    ON    FEVERS,    DROPSY,    GOUT,  RHEUMATISM,   &c.  &c. 

In  one  neat  8vo.  volume,     pp.  450. 


CLYMER  (MEREDITH),  M.  D.,  &c. 
FEVERS;     THEIR    DIAGNOSIS,    PATHOLOGY,    AND    TREATMENT. 

Prepared  and  Edited,  with  large  Additions,  from  the  Essays  on  Fever  in  Tweedie's  Library  of 
Practical  Medicine.     In  one  octavo  volume,  of  600  pages. 


CARSON   (JOSEPH),  M.  D., 

Professor  of  Materia  Medica  and  Pharmacy  in  the  University  of  Pennsylvania. 

SYNOPSIS  OF  THE  COURSE  OF  LECTURES  ON  MATERIA  MEDICA 

AND  PHARMACY,  delivered  in  the  University  of  Pennsylvania.     In  one  very  neat  octavo 
volume,  of  208  pages.  ^ 


BLANCHARD  &  LEA'S   MEDICAL 


CARPENTER  (WILLIAM    B.),   M.  D.,  F.  R.  S.,  &.C., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

PRINCIPLES  OF  HUMAN  PHYSIOLOGY;  with  their  chief  applications  to 

Psychology,  Patholog-y,  Therapeutics,  Hygiene,  and  Forensic  Medicine.    Fifth  Antierican,  from 

the  fourth  and  enlarged  London  edition.    "With  three  hundred  and  fourteen  illustrations.    Edited, 

with  additions,  by  Francis  Gurney  Smith,  M.D.,  Professor  of  the  Institutes  of  Medicine  in  the 

Pennsylvania  Medical  College,  &c.    In  one  very  large  and  beautiful  octavo  volume,  of  about  1100 

laro-e  pages,  handsomely  printed  and  strongly  bound  in  leather,  with  raised  bands.    New  edition. 

(JLately  Issued.)  v 

This  edition  has  been  printed  from  sheets  prepared  for  the  purpose  by  the  author,  who  has 

introduced  nearly  one  hundred  illustrations  not  in  the  London  edition;  while  it  has  also  enjoyed 

the  advantage  of  a  careful  superintendence  on  the  part  of  the  editor,  who  has  added  notices  of  such 

more  recent  investigations  as  had  escaped  the  author's  attention.     Neither  care  nor  expense  has 

been  spared  in  the  mechanical  execution  of  the  work  to  render  it  superior  to  former  editions,  and  it 

IS  confidently  presented  as  in  every  way  one  of  the  handsomest  volumes  as  yet  placed  before  the 

medical  profession  in  this  country. 


The  most  complete  work  on  the  science  in  our 
language. — Am.  Med.  Journal. 

The  most  complete  exposition  of  physiology  which 
any  language  can  at  present  give. — Brit,  and  For. 
Med.-Chirurs.  Review. 

We  have  thus  adverted  to  some  of  the  leading 
"additions  and  alterations,"  which  have  been  in- 
troduced by  the  author  into  this  edition  of  his  phy- 
siology. These  will  be  found,  however,  very  far  to 
exceed  the  ordinary  limits  of  a  new  edition,  "  the 
old  materials  having  been  incorporated  with  the 
now,  rather  than  the  new  with  the  old."  It  now 
certainly  presents  the  most  complete  treatise  on  the 
r-iibject  within  the  reach  of  the  American  reader  ; 
and  while,  for  availability  as  a  text-book,  we  may 
perhaps  regret  its  growth  in  bulk,  we  are  sure  that 
V.he  student  of  physiology  will  feel  the  impossibility 
of  presenting  a  thorough  digest  of  the  facts  of  the 
(science  within  a  more  limited  compass. — Medical 
Exatniner . 

The  greatest,  the  most  reliable,  and  the  best  book 
on  the  subject  which  we  know  of  in  the  English 
language. — Stethoscope. 

The  most  comi)lete  work  now  extant  in  our  lan- 
guage.— N.  O.  Med.  Register. 

The  changes  are  too  numerous  to  admit  of  an  ex- 
tended notice  in  this  place.  At  every  point  where 
the  recent  diligent  labors  of  organic  chemists  and 
micrographers  have  furnished  interesting  and  valu- 
able facts,  they  have  been  appropriated,  and  no  pains 
have  been  spared,  in  so  incorporating  and  arranging 
them  that  the  work  may  constitute  one  harmonious 
system. — Southern  Med.  and  Surg.  Journal. 


The  best  text-book  in  the  language  on  this  ex- 
tensive subject. — London  Med.  Times. 

A  complete  cyclopEedia  of  this  branch  of  science. 
—N.  Y.  Med.  Times. 

The  standard  of  authority  on  physiological  sub- 
jects. *  *  *  In  the  present  edition,  to  particularize 
the  alterations  and  additions  which  have  been  made, 
would  require  a  review  of  the  whole  work,  since 
scarcely  a  subject  has  not  been  revised  and  altered, 
added  to,  or  entirely  remodelled  to  adapt  it  to  the 
present  state  of  the  science. — Charleston  Med.  Journ. 

Any  reader  who  desires  a  treatise  on  physiology 
may  feel  himself  entirely  safe  in  ordering  this. — 
Western  Med.  and  Surg.  Journal. 

From  this  hasty  and  imperfect  allusion  it  will  he 
seen  by  our  readers  that  the  alterations  and  addi- 
tions to  this  edition  render  it  almost  a  new  work — 
and  we  can  assure  our  readers  that  it  is  one  of  the 
best  summaries  of  the  existing  facts  of  physiological 
science  within  the  reach  of  the  English  student  and 
physician. — N.  Y.  Journal  of  Medicine. 

The  profession  of  this  country,  and  perhaps  also 
of  Europe,  have  anxiously  and  for  some  time  awaited 
the  announcement  of  this  new  edition  of  Carpenter's 
Human  Physiology.  His  former  editions  have  for 
many  years  been  almost  the  only  text-book  on  Phy- 
siology in  all  our  medical  schools,  and  its  circula- 
tion among  the  profession  has  been  unsurpassed  by 
any  work  in  any  department  of  medical  science. 

It  is  quite  unnecessary  for  us  to  speak  of  this 
work  as  its  merits  would  justify.  The  mere  an- 
nouncement of  its  appearance  will  afford  the  highest 
pleasure  to  every  student  of  Physiology,  while  its 
perusal  will  be  of  infinite  service  in  advancing 
physiological  science. — Ohio  Med.  and  Surg.  Journ. 


BY   THE   SAME   AUTHOR.      (In  ProS.) 

PRINCIPLES    OF    GENERAL    AND    COMPARATIVE    PHYSIOLOGY. 

Intended  as  an  Introduction  to  the  Study  of  Human  Physiology;  and  as  a  Guide  to  the  Philo- 
sophical pursuit  of  Natural  History.  New  and  improved  edition.  In  one  large  and  handsome 
octavo  volume,  with  several  hundred  beautiful  illustrations. 

The  very  thorough  revision,  and  extensive  alterations  made  by  the  author,  have  caused  a  delay 
in  the  promised  appearance  of  this  work.  It  is  now,  however,  at  press,  and  may  be  expected  for 
publication  during  the  ensuing  summer.  A  very  large  number  of  new  and  important  illustrations 
have  been  prepared  for  it,  and  the  publishers  trust  to  render  the  volume  worthy  of  its  extended 
reputation  in  every  point  of  typograpliical  finish,  as  one  of  the  handsomest  productions  of  the 
American  press.     A  few  notices  of  the  former  edition  are  appended. 

critical,  and  unprejudiced  view  of  those  labors  and 
of  combining  the  varied,  heterogeneous  materials  at 
his  disposal,  so  as  to  form  an  harmonious  whole. 
We  feel  that  this  abstract  can  give  the  reader  a  very 
imperfect  idea  of  the  fulness  of  this  work,  and  no 
idea  of  its  unity,  of  the  admirable  manner  in  which 
material  has  been  brought,  from  the  most  various 
sources,  to  conduce  to  its  completeness,  of  the  lucid- 
ity of  the  reasoning  it  contains,  or  of  the  clearness 
of  language  in  which  the  whole  is  clothed.  Not  the 
profession  only,  but  the  scientific  world  at  large, 
must  feel  deeply  indebted  to  Dr.  Carpenter  for  tliis 
great  work.  It  must,  indeed,  add  largely  even  t« 
his  high  reputation. — Medical  Times. 


Without  pretending  to  it,  it  is  an  Encyclopedia  of 
the  subject,  accurate  and  complete  in  all  respects — 
a  truthful  reflection  of  the  advanced  state  at  which 
the  science  has  now  arrived. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  truly  magnificent  work — in  itself  a  perfect  phy- 
siological study. — Ranking's  Abstract. 

This  work  stands  without  its  fellow.  It  is  one 
few  men  in  Europe  could  have  undertaken ;  it  is  one 
no  man,  we  believe,  could  have  brought  to  so  suc- 
cessful an  issue  as  Dr.  Carpenter.  It  required  for 
its  production  a  physiologist  at  once  deeply  read  in 
the  labors  of  others,  capable  of  taking  a  general. 


BY  THE  SAME  AUTHOR.     (Preparing.) 


THE  MICROSCOPE  AND  ITS  REVELATIONS. 

beautifully  illustrated  with  plates  and  wood-cuts. 


In  one  handsome  volume, 


AND    SCIENTIFIC    PUBLICATIONS. 


CARPENTER  (WILLIAM  B.),   M.  D.,  F.  R.  S., 

Examiner  in  Physiology  and  Comparative  Anatomy  in  the  University  of  London. 

ELEMENTS  (OR  MANUAL)  OF  PHYSIOLOGY,  INCLUDING  PHYSIO- 
LOGICAL ANATOMY.  Second  American,  from  a  new  and  revised  London  edition.  Witli 
one  hundred  and  ninety  illustrations.     In  one  very  handsome  octavo  volume. 

In  publishing  the  first  edition  of  this  vs^ork,  its  title  was  altered  from  that  of  the  London  volume, 
by  the  substitution  of  the  word  "  Elements"  for  that  of  "  Manual,"  and  with  the  author's  sanction 
the  title  of  "  Elements"  is  still  retained  as  being  more  expressive  of  the  scope  of  the  treatise.  A 
comparison  of  the  present  edition  with  the  former  one  will  show  a  material  improvement,  the 
author  having  revised  it  thoroughly,  with  a  view  of  rendering  it  completely  on  a  level  with  the 
most  advanced  state  of  the  science.  By  condensing  the  less  important  portions,  these  numerous 
additions  have  been  introduced  without  materially  increasing  the  bulk  of  the  volume,  and  while 
numerous  illustrations  have  been  added,  and  the  general  execution  of  the  work  improved,  it  has 
been  kept  at  its  former  very  moderate  price. 


To  say  that  it  is  the  best  manual  of  Physiology 
now  before  the  public,  ■would  not  do  sufficient  justice 
to  the  author. — Buffalo  Medical  Journal. 

In  his  former  works  it  would  seem  that  he  had 
exhausted  the  subject  of  Physiology.  In  the  present, 
he  gives  the  essence,  as  it  were,  of  the  whole. — N.  Y. 
Journal  of  Medicine. 

Those  who  have  occasion  for  an  elementary  trea- 
tise on  Physiology,  cannot  do  better  than  to  possess 
themselves  of  the  manual  of  Dr.  Carpenter. — Medical 
Examiner. 


The  best  and  most  complete  expose  of  modern 
Physiology,  in  one  volume,  extant  in  the  English 
language. — St.  Louis  Medical  Journal. 

With  such  an  aid  in  his  hand,  there  is  no  excuse 
for  the  ignorance  often  displayed  respecting  the  sub- 
jects of  which  it  treats.  From  its  unpretending  di- 
mensions, it  may  not  be  so  esteemed  by  those  anxious 
to  make  a  par.ade  of  their  erudition  ;  but  w^hoever 
masters  its  contents  will  have  reason  to  be  proud  of 
his  physiological  acquirements.  The  illustrations 
are  well  selected  and  finely  executed. — Dublin  Med, 
Press. 


BY   THE   SAME   AtlTHOR. 

A  PRIZE  ESSAY  ON  THE  USE  OF  ALCOHOLIC  LIQUORS  IN  HEALTH 

AND  DISEASE.     New  edition,  with  a  Preface  by  D.  F.  Condie,  M.  D.,  and  explanations  of 
scientific  words.     In  one  neat  12mo.  volume.     {Now  Ready.) 

This  new  edition  has  been  prepared  with  a  view  to  an  extended  circulation  of  this  important  little 
work,  which  is  universally  recognized  as  the  best  exponent  of  the  laws  of  physiology  and  pathology 
applied  to  the  subject  of  intoxicating  liquors,  in  a  form  suited  both  for  the  profession  and  the  public. 
To  secure  a  wider  dissemination  of  its  doctrines  the  publishers  have  done  up  copies  in  flexible 
cloth,  suitable  for  mailing,  which  will  be  forwarded  through  the  post-oflice,  free,  on  receipt  of  fifty 
cents.     Societies  and  others  supplied  in  quantities  for  distribution  at  a  liberal  deduction. 


CHELIUS   (J.  M.),   M.  D., 

Professor  of  Surgery  in  the  University  of  Heidelberg,  &c. 

A  SYSTEM  OF  SURG-ERY.     Translated  from  the  G-erraan,  and  accompanied 

with  additional  Notes  and  References,  by  John  F.  South.     Complete  in  three  very  large  octavo 
volumes,  of  nearly  2200  pages,  strongly  bound,  with  raised  bands  and  double  titles. 


We  do  not  hesitate  to  pronounce  it  the  best  and 
most  comprehensive  system  of  modern  surgery  with 
Virhich  we  are  acquainted. — Medico-C hirurgical  Re- 
view. 

The  fullest  and  ablest  digest  extant  of  all  that  re- 
lates to  the  present  advanced  state  of  surgical  pa- 
thology.— American  Medical  Journal. 

As  complete  as  any  system  of  Surgery  can  well 
be. — Southern  Medical  and  Surgical  Journal . 


The  most  learned  and  complete  systematic  treatise 
now  extant. — Edinburgh  Medical  Journal. 

A  complete  encyclopaedia  of  surgical  science — a 
very  complete  surgical  library — by  far  the  most 
complete  and  scientitic  system  of  surgery  in  the 
English  langnage. — N.  Y.  Journal  of  Medicine. 

The  most  extensive  and  comprehensive  account  of 
the  art  and  science  of  Surgery  in  our  language. — 
Lancet. 


CHRISTISON  (ROBERT),  M.  D.,  V.  P.  R.  S.  E.,  &c. 
A  DISPENSATORY;  or,  Commentary  on  the  Pharmacopoeias  of  Great  Britain 

and  the  United  States;  comprising  the  Natural  History,  Description,  Chemistry,  Pharmacy,  Ac- 
tions, Uses,  and  Doses  of  the  Articles  of  the  Materia  Medica.  Second  edition,  revised  and  im- 
proved, with  a  Supplement  containing  the  most  important  New  Remedies.  With  copious  Addi- 
tions, and  two  hundred  and  thirteen  large  wood-engravings.  By  R.  Eglesfeld  Griffith,  M.  D. 
In  one  very  large  and  handsome  octavo  volume,  of  over  1000  pages. 


It  is  not  needful  that  we  should  compare  it  with 
the  other  pharmacopoeias  extant,  which  enjoy  and 
merit  the  confidence  of  the  profession  :  it  is  enough 
to  say  that  it  appears  to  us  as  perfect  as  a  Dispensa- 
tory, in  the  present  state  of  pharmaceutical  science, 
could  be  made.  If  it  omits  any  details  pertaining  to 
this  branch  of  knowledge  which  the  student  has  a 
right  to  expect  in  such  a  work,  we  confess  the  omis- 
sion has  escaped  our  scrutiny.  We  cordially  recom- 
mend this  work  to  such  of  our  readers  as  are  in  need 
of  a  Dispensatory.  They  cannot  make  choice  of  a 
better. — Western  Journ.  of  Medicine  and  Surgery. 


There  is  not  in  any  language  a  more  complete  and 
perfect  Treatise. — JV.  Y.  Annalist. 

In  conclusion,  we  need  scarcely  say  that  we 
strongly  recommend  this  work  to  all  classes  of  our 
readers.  As  a  Dispensatory  and  commentary  on  the 
PharmacopcEias,  it  is  unrivalled  in  the  Englisti  or 
any  other  language. — The  Dublin  Quarterly  Journal . 

We  earnestly  recommend  Dr.  Christison's  Dis- 
pensatory to  all  our  readers,  as  an  indispensable 
companion,  not  in  theStudy  only,  but  in  the  Surgery 
also. — British  and  Foreign  Medical  Review, 


8 


BLANCHARD  &  LEA'S  MEDICAL 


CONDIE  {D.  F.),  M.  D.,  &c. 
A  PRACTICAL  TREATISE  ON  THE  DISEASES  OP  CHILDREN. 


Fourth 


edition,  revised  and  augmented.  In  one  large  volume,  8vo.,  of  nearly  750  pages.  (Just  Issued.) 
From  the  Author's  Preface. 

The  demand  for  another  edition  has  afforded  the  author  an  opportunity  of  again  subjecting  the 
entire  treatise  to  a  careful  revision,  and  of  incorporating  in  it  every  important  observation  recorded 
since  the  appearance  of  the  last  edition,  in  reference  to  the  pathology  and  therapeutics  of  the  several 
diseases  of  vi^hich  it  treats. 

In  the  preparation  of  the  present  edition,  as  in  those  which  have  preceded,  while  the  author  has 
appropriated  to  his  use  every  important  fact  that  he  has  ibuiid  recorded  in  the  works  of  others, 
having  a  direct  bearing  upon  either  of  the  subjects  of  which  he  treats,  and  the  numerous  valuable 
observations — pathological  as  well  as  practical — dispersed  throughout  the  pages  of  the  medical 
journals  of  Europe  and  America,  he  has,  nevertheless,  relied  chiefly  upon  his  own  observations  and 
experience,  acquired  during  a  long  and  somewhat  extensive  practice,  and  under  circumstances  pe- 
culiarly well  adapted  for  ihe  clinical  study  of  the  diseases  of  early  life. 

Every  species  of  hypothetical  reasoning  has,  as  much  as  possible,  been  avoided.  The  author  lias 
endeavored  throiighou/ihe  work  to  confine  himself  to  a  simple  statement  of  well-ascertained  patho- 
logical facts,  and  plain  therapeutical  directions — his  chief  desire  being  to  render  it  what  its  title 
imports  it  to  be,  a  practical  treatise  on  the  diseases  of  children. 


Dr.  Condie's  scholarship,  acumerij  industry,  and 
practical  sense  are  manifested  in  this,  as  in  all  his 
numerous  contributions  to  science. — Dr.  Holmes''s 
Report  to  the  American  Medical  Association. 

Taken  as  a  whole,  in  our  judgment.  Dr.  Condie's 
Treatise  is  the  one  from  the  perusal  of  "which  the 
practitioner  in  this  country  will  rise  with  the  great- 
est satisfaction  — Western  Journal  of  Medicine  and 
'Surgery. 

One  of  the  best  works  upon  the  Diseases  of  Chil- 
dren in  the  English  language. — Western  Lancet. 

Perhaps  the  most  full  and  complete  work  now  be- 
fore the  profession  of  the  United  States;  indeed,  we 
may  say  in  the  English  language.  It  is  vastly  supe- 
rior to  most  of  its  predecessors. — Transylvania  Med. 
Journal. 


We  feel  assured  from  actual  experience  that  no 
physician's  library  can  be  complete  without  a  copy 
of  this  work. — N.  Y.  Journal  of  Medicine. 

A  veritable  ptediatric  encyclopsedia,  and  an  honor 
to  American  medical  literature. — Ohio  Medical  and 
Surgical  Journal. 

We  feel  persuaded  that  the  American  medical  pro- 
fession will  soon  regard  it  not  only  as  a  very  good, 
but  as  the  very  best  "  Practical  Treatise  on  the 
Diseases  of  Children." — American  Medical  Journal. 

We  pronounced  the  first  edition  to  be  the  best 
work  on  the  diseases  of  children  in  the  English 
language,  and,  notwithstandin";  all  that  has  been 
published,  we  still  regard  it  in  that  light.— Med^cai 
Examiner. 


COOPER  (BRANSBY   B.),  F.  R.  S., 

Senior  Surgeon  to  Guy's  Hospital,  &c. 

LECTURES  ON  THE   PRINCIPLES   AND   PRACTICE   OF   SURGERY. 

In  one  very  large  octavo  volume,  of  750  pages.    (Lately  Issued). 


For  twenty-five  years  Mr.  Bransby  Cooper  has 
been  surgeon  to  Guy's  Hospital;  and  the  volume 
before  us  may  be  said  to  consist  of  an  account  of 
the  results  of  his  surgical  experience  during  that 
long  period.    We  cordially  recommend  Mr.  Bransby 


Cooper's  Lectures  as  a  most  valuable  addition  to 
our  surgical  literature,  and  one  which  cannot  fail 
to  be  of  service  both  to  students  and  to  those  who 
are  actively  engaged  in  the  practice  of  their  profes- 
sion.—TAe  Lancet, 


COOPER  (SIR  ASTLEY  P.),  F.  R.  S.,  &c. 
A  TREATISE  ON  DISLOCATIONS  AND  FRACTURES  OF  THE  JOINTS. 

Edited  by  Bransby  B.  Cooper,  F.  R.  S,,  &;c.  "With  additional  Observations  by  Prof  J.  C. 
Warren.  A  new  American  edition.  In  one  handsome  octavo  volume,  with  numerous  illustra- 
tions on  wood. 

BY   THE   SAME   AUTHOR. 

ON  THE  ANATOMY  AND  TREATMENT  OF  ABDOMINAL  HERNIA. 

One  large  volume,  imperial  8vo.,  with  over  130  lithographic  figures. 

BY   THE   SAME   AUTHOR. 

ON   THE   STRUCTURE  AND   DISEASES   OF  THE  TESTIS,  AND  ON 

THE  THYMUS  GLAND.    One  vol.  imperial  8vo.,  with  177  figures,  on  29  plates. 


BY  THE   SAME   AUTHOR. 

ON  THE  ANATOMY  AND  DISEASES   OF  THE   BREAST,  with  twenty- 
five  Miscellaneous  and  Surgical  Papers.     One  large  volume,  imperial  8vo.,  with  252  figures,  on 
36  plates. 
These  last  three  volumes  complete  the  surgical  writings  of  Sir  Astley  Cooper.     They  are  very 

handsomely  printed,  with  a  large  number  of  lithographic  plates,  executed  in  the  best  style,  and  are 

presented  at  exceedingly  tow  prices. 


AND    SCIENTIFIC    PUBLICATIONS. 


CHURCHILL  (FLEETWOOD),  M.  D.,  M.  R.  I.  A. 
ON  THE  THEORY  AND  PRACTICE  OF  MIDWIFERY.  A  new  American, 

from  the  last  and  improved  English  edition.  Edited,  with  Notes  and  Additions,  by  D.  Francis 
CoNDiE,  M.  D.,  author  of  a  "Practical  Treatise  on  the  Diseases  of  Children,"  &c.  With  139 
illustrations.     In  one  very  handsome  octavo  volume,  pp.  510.     (Lately  Issued.) 


To  bestow  praise  on  a  book  that  has  received  such 
marked  approbation  would  be  superfluous.  We  need 
only  say,  therefore,  that  if  the  first  edition  ^vas 
thought  worthy  of  a  favorable  reception  by  the 
medical  public,  we  can  confidently  affirm  that  this 
will  be  found  much  more  so.  The  lecturer,  the 
practitioner,  and  the  student,  may  all  have  recourse 
to  its  pages,  and  derive  from  their  perusal  much  in- 
terest and  instruction  in  everything  relating  to  theo- 
retical and  practical  midwifery. — Dublin  Quarterly 
Journal  of  Medical  Science. 

A  work  of  very  great  merit,  and  such  as  we  can 
confidently  recommend  to  the  study  of  every  obste- 
tric practitioner. — London  Medical  Gazette. 

This  is  certainly  the  most  perfect  system  extant. 
It  is  the  best  adapted  for  the  purposes  of  a  text- 
book, and  that  which  he  whose  necessities  confine 
him  to  one  book,  should  select  in  preference  to  all 
others. — Southern  Medical  and  Surgical  Journal. 

The  most  popular  work  on  midwifery  ever  issued 
from  the  American  press. — Charleston  Med.  Journal. 

Were  we  reduced  to  the  necessity  of  having  hut 
one  work  on  midwifery,  and  per7nitted  to  choose, 
we  would  unhesitatingly  take  Churchill. — Western 
Med.  and  Surg.  Journal. 

It  is  impossible  to  conceive  a  more  useful  and 
elegant  manual  than  Dr.  Churchill's  Practice  of 
Midwiferj'^. — Provincial  Medical  Journal. 

Certainly,  in  our  opinion,  the  very  best  work  on 
the  subject  which  exists. — N.  Y.  Annalist. 


No  work  holds  a  higher  position,  or  is  more  de- 
serving of  being  placed  in  the  hands  of  the  tyro, 
the  advanced  student,  or  the  practitioner. — Medical 
Examiner. 

Previous  editions,  under  the  editorial  supervision 
of  Prof  R.  M.  Huston,  have  been  received  with 
marked  favor,  and  they  deserved  it;  but  this,  re- 
printed from  a  very  late  Dublin  edition,  carefully, 
revised  and  brought  up  by  the  author  to  the  present 
time,  does  present  an  unusually  accurate  and  able 
exposition  of  every  important  particular  embraced 
in  the  department  of  midwifery.  *  *  The  clearness, 
directness,  and  precision  of  its  teachings,  together 
with  the  great  amount  of  statistical  research  which 
its  text  exhibits,  have  served  to  place  it  already  in 
the  foremost  rank  of  works  in  this  department  of  re- 
medial science. — N.  O.  Med.  and  Surg.  Journal. 

In  our  opinion,  it  forms  one  of  the  best  if  not  the 
very  best  text-book  and  epitome  of  obstetric  science 
which  we  at  present  possess  in  the  English  laa- 
gnsige.— Monthly  Journal  of  Medical  Science. 

The  clearness  and  precision  of  style  in  which  it  is 
written,  and  the  greatamountof  statistical  research 
which  it  contains,  have  served  to  place  it  in  the  first 
rank  of  works  in  this  departmentof  medical  science. 
— N.  Y.  Journal  of  Medicine. 

Few  treatises  will  be  found  better  adapted  as  a 
text-book  for  the  student,  or  as  a  manual  for  the 
frequent  consultation  of  the  young  practitioner. — 
American  Medical  Journal. 


BY   THE   SAME   AUTHOR. 


ON  THE  DISEASES  OF  INFANTS  AND  CHILDREN. 

handsome  volume  of  over  600  pages. 


In  one  large  and 


We  regard  this  volume  as  possessing  more  claims 
to  completeness  than  any  other  of  the  kind  with 
which  we  are  acquainted.  Most  cordially  and  earn- 
estly, therefore,  do  we  commend  it  to  our  profession- 
al brethren,  and  we  feel  assured  that  the  stamp  of 
their  approbation  will  indue  time  be  impressed  upon 
it.  After  an  attentive  perusal  of  its  contents,  we 
hesitate  not  to  say,  that  it  is  one  of  the  most  com- 
prehensive ever  ^vritten  upon  the  diseases  of  chil- 
dren, and  that,  for  copiousness  of  reference,  extent  of 
research,  and  perspicuity  of  detail,  it  is  scarcely  to 
be  equalled,  and  not  to  be  excelled,  in  any  lan- 
guage.— Dublin  Quarterly  Journal. 

After  this  meagre,  and  we  knovr,  very  imperfect 
notice  of  Dr.  Churchill's  work,  we  shall  conclude 
by  saying,  that  it  is  one  that  cannot  fail  from  its  co- 
piousness, extensive  research,  and  general  accuracy, 
to  exalt  still  higher  the  reputation  of  tiie  author  in 
this  country.  The  American  reader  will  be  particu- 
larly pleased  to  find  that  Dr.  Churchill  has  done  full 
justice  throughout  his  work  to  the  various  A  meriean 
authors  on  this  subject.  The  names  of  Dewees, 
Eberle,  Condie,  and  Stewart,  occur  on  nearly  every 
page,  and  these  authors  are  constantly  referred  to  by 
the  author  in  terms  of  the  highest  praise,  and  with 
the  most  liberal  courtesy. — The  Medical  Examiner. 


The  present  volume  will  sustain  the  reputation 
acquired  by  the  author  from  his  previous  w^orks. 
The  reader  will  find  in  it  full  and  judicious  direc- 
tions for  the  management  of  infants  at  birth,  and  a 
compendious,  but  clear  account  of  the  diseases  to 
which  children  are  liable,  and  the  most  successful 
mode  of  treating  them.  We  must  not  close  this  no- 
tice without  calling  attention  to  the  author's  style, 
which  is  perspicuous  and  polished  to  a  degree,  we 
regret  to  say,  not  generally  characteristic  of  medical 
works.  We  recommend  the  work  of  Dr.  Churchill 
most  cordially,  both  to  students  and  practitioners, 
as  a  valuable  and  reliable  guide  in  the  treatment  of 
the  diseases  of  children. — Am.  Journ.  of  the  Med. 
Sciences. 

We  know  of  no  work  on  this  department  of  Prac- 
tical Medicine  \vhich  presents  so  candid  and  unpre- 
judiced a  statement  or  posting  up  of  our  actual 
knowledge  as  this. — N.  Y.  Journal  of  Medicine. 

Its  claims  to  merit  both  as  a  scientific  and  practi- 
cal work,  are  of  the  highest  order.  Whilst  we 
would  not  elevate  it  above  every  other  treatise  on 
the  same  subject,  we  certainly  believe  that  very  few 
are  equal  to  it,  and  none  superior. — Southern  Med. 
and  Surgical  Journal, 


BY  THE   SAME   AUTHOR. 


ESSAYS  ON  THE  PUERPERAL  FEVER,  AND  OTHER  DISEASES  PE- 

CULIAU  TO  WOMEN.     Selected  from  the  wriiingsof  British  Authors  previous  to  the  close  of 
the  Eighteenth  Century.    In  one  neat  octavo  volume,  of  about  four  hundred  and  fifty  pages. 


To  these  papers  Dr.  Churchill  has  appended  notes, 
embodying  whatever  information  has  been  laid  be- 
fore the  profession  since  their  authors'  time.  He  has 
also  prefixed  to  the  Essays  on  Puerperal  Fever, 
which  occupy  the  larger  portion  of  the  volume,  an 
interesting  historical  sketch  of  the  principal  epi- 


demics of  that  disease.  The  w^hole  forms  a  very 
valuable  collection  of  papers,  by  professionaMvriters 
of  eminence,  on  some  of  the  most  important  accidents 
to  whicli  the  puerperal  female  is  liable. — American 
Journal  of  Medical  Sciences. 


10 


BLANCHARD    &    LEA'S    MEDICAL 


CHURCHILL  (FLEETWOOD),    M.  D.,  M.  R.  I.  A.,    &c. 

ON  THE  DISEASES  OF  WOMEN;  including  those  of  Pregnancy  and  Child- 
bed. A  new  American  edition,  revised  by  the  Author.  With  Notes  and  Additions,  by  D  Fran- 
cis CoNDiE,  M.  D.,  author  of  "A  Practical  Treatise  on  the  Diseases  of  Children."  In  one  large 
and  handsome  octavo  volume,  with  wood-cuts,  pp.  684.     {Just  Issued.) 

From  the  Author'' s  Preface. 
In  reviewing  this  edition,  at  the  request  of  my  American  publishers,  I  have  inserted  several  new 
sections  and  chapters,  and  I  have  added,  I  believe,  all  the  information  we  have  derived  from  recent 
researches;  in  addition  to  which  the  publishers  have  been  fortunate  enough  to  secure  the  services 
of  an  able  and  highly  esteemed  editor  in  Dr.  Condie. 


We  now  regretfully  take  leave  of  Dr.  Churchill's 
book.  Had  our  typographical  limits  permitted,  we 
should  gladly  have  borrowed  more  from  its  richly 
stored  pages.  In  conclusion,  we  heartily  recom- 
mend it  to  the  profession,  and  would  at  the  same 
time  express  our  fi  rm  conviction  that  it  will  not  only 
add  to  the  reputation  of  its  author,  but  will  prove  a 
work  of  great  and  extensive  utility  to  obstetric 
practitioners. — Dublin  Medical  Press. 

Former  editions  of  this  work  have  been  noticed  in 
previous  numbers  of  the  Journal.  The  sentiments  of 
high  commendation  expressed  in  those  notices,  have 
only  to  be  repeated  in  this;  not  from  the  fact  that 
the  profession  at  large  are  not  aware  of  the  high 
merits  which  this  work  really  possesses,  but  from  a 
desire  to  see  the  principles  and  doctrines  therein 
contained  more  generally  recognized,  and  more  uni- 
versally carried  out  in  practice. — N.  Y.  Journal  of 
Medicine. 

We  know  of  no  author  who  deserves  that  appro- 
bation, on  "  the  diseases  of  females,"  to  the  same 
extent  that  Dr.  Churchill  does.  His,  indeed,  is  the 
only  thorough  treatise  we  know  of  on  the  subject; 
and  it  may  be  commended  to  practitioners  and  stu- 
dents as  a  masterpiece  in  its  particular  department. 
The  former  editions  of  this  work  have  been  com- 
mended strongly  in  this  journal,  and  they  have  won 
their  way  to  an  extended,  and  a  well-deserved  popu- 


larity. This  fifth  edition,  before  us.  is  well  calcu- 
lated to  maintain  Dr.  Churchill's  high  reputation. 
It  was  revised  and  enlarged  by  the  author,  for  his 
American  publishers,  and  it  seems  to  us  that  there  i« 
scarcely  any  species  of  desirable  information  on  its 
subjects  that  may  not  be  found  in  this  w^ork. — The 
Western  Journal  of  Medicine  and  Surgery. 

^Ve  are  gratified  to  announce  a  new  and  revised 
edition  of  Dr.  Churchill's  valuable  work  on  the  dis- 
eases of  females  We  have  ever  regarded  it  as  one 
of  the  very  best  works  on  the  subjects  embraced 
within  its  scope,  in  the  English  language;  and  tha 
present  edition,  enlarged  and  revised  by  the  author, 
renders  it  still  more  entitled  to  the  confidence  of  the 
profession.  The  valuable  notes  of  Prof.  Huston 
have  been  retained,  and  contribute,  in  no  small  de- 
gree, to  enhance  the  value  of  the  work.  It  is  a 
source  of  congratulation  that  the  publishers  have 
permitted  the  author  to  be,  in  this  instance,  his 
own  editor,  thus  securing  all  the  revision  which 
an  anthor  alone  is  capable  of  making, — The  Western 
Lancet. 

Asa  comprehensive  manual  for  students,  or  a 
work  of  reference  for  practitioners,  we  only  speak 
with  common  justice  when  we  say  that  it  surpasses 
any  other  that  has  ever  issued  on  the  same  sub- 
ject from  the  British  press. — The  Dublin  Quarterly 
Journal, 


DEWEES   (W.    P.),   M.D.,    &.C. 
A   COMPREHENSIVE   SYSTEM  OF   MIDWIFERY.     Illustrated  by  occa- 
sional Cases  and  many  Engravings.     Twelfth  edition,  with  the  Author's  last  Improvements  and 
Corrections.     In  one  octavo  volume,  of  600  pages.     {Just  Issued.) 


BY   THE   SAME   AUTHOR. 


A  TREATISE  ON  THE  PHYSICAL  AND  MEDICAL  TREATMENT  OP 

CHILDREN.     Tenth  edition.     In  one  volume,  octavo,  548  pages.     {Just  Issued.) 

/  BY   THE   SAME   AUTHOR. 

A  TREATISE  ON   THE   DISEASES   OF   FEMALES.     Tenth   edition.     In 

one  volume,  octavo,  532  pages,  with  plates.     {Just  Issued.) 


DICKSON   (PROFESSOR   S.    H.),    M.D. 
ESSAYS  ON  LIFE,  SLEEP,  PAIN,  INTELLECTION,  HYGIENE,  AND 

DEATH.     In  one  very  handsome  volume,  royal  12mo. 


DANA   (JAMES    D). 
ZOOPHYTES  AND  CORALS.     In  one  volume,  imperial  quarto,  extra  cloth, 

with  wood-cuts. 


ALSO, 


AN  ATLAS  TO  THE  ABOVE,  one  volume,  imperial  folio,  with  sixty-one  mag- 
nificent plates,  colored  after  nature.    Bound  in  half  morocco. 


ALSO, 


ON    THE    STRUCTURE    AND    CLASSIFICATION    OF    ZOOPHYTES. 

Sold  separate,  one  vol.,  cloth. 


DE    LA    BECHE   (SIR    HENRY    T,),   F.  R.  S.,  Stc. 
THE  GEOLOGICAL  OBSERVER.     In  one  very  large   and  handsome  octavo 

volume,  of  700  pages.    With  over  three  hundred  wood-cuts.     {Lately  Issued.) 


AND    SCIENTIFIC    PUBLICATIONS. 


11 


DRUITT   (ROBERT),   M.R.  C.S.,   Sic. 
THE  PRINCIPLES  AND  PRACTICE   OF  MODERN   SURGERY.     A  new 

American,  from  the  improved  London  edition.  Edited  by  F.  W.  Sargent,  M.  D.,  author  of 
"Minor  Surgerjr,"  &:c.  Illustrated  with  one  hundred  and  ninety-three  wood-engravings.  la 
one  very  handsomely  printed  octavo  volume,  of  576  large  pages. 


Dr.Druitt's  researches  into  the  literature  of  his 
subject  have  been  not  only  extensile,  but  well  di- 
rected;  the  most  discordant  authors  are  fairly  and 
impartially  quoted,  and,  while  due  credit  is  given 
to  each,  their  respective  merits  are  weighed  with 
an  unprejudiced  hand.  The  grain  of  wheat  is  pre- 
served, and  the  chaff  is  unmercifully  stripped  off. 
The  arrangement  is  simple  and  philosophical,  and 
the  style,  though  clear  and  interesting,  is  so  precise, 
that  the  book  contains  more  information  condensed 
into  a  few  words  than  any  other  surgical  work  with 
^vhich  we  are  acquainted. — London  Medical  Times 
and  Gazette,  February  IS,  1S54. 

No  work,  in  our  opinion,  equals  it  in  presenting 
Eo  much  valuable  surgical  matter  in  so  small  a 
compass. — St.  Louis  Med.  and  Surgical  Journal. 

Druitt's  Surgery'  is  too  well  kno^vn  to  the  Ameri- 
can medical  profession  to  require  its  announcement 
anywhere.  Probably  no  T.vork  of  the  kind  has  ever 
been  more  cordially  received  and  extensively  circu- 
lated than  this.  The  fact  that  it  comprehends  in  a 
comparatively  small  compass,  all  the  essential  ele- 
ments of  theoretical  and  practical  Surgery — that  it 
is  found  to  contain  reliable  and  authentic  informa- 
tion on  the  nature  and  treatment  of  nearly  all  surgi- 
cal affections — is  a  sufficient  reason  for  the  liberal 
patronage  it  has  obtained.  The  editor.  Dr.  F.  W. 
Sargent,  has  contributed  much  to  enhance  the  value 
of  the  work,  by  such  American  improvements  as  are 
calculated  mo|E  perfectly  to  adapt  it  to  our  own 
views  and  practice  in  this  country.  It  abounds 
everywhere  with  spirited  and  life-like  illustrations, 
which  to  the  young  surgeon,  especially,  are  of  no 
minor  considsration.  Every  medical  man  frequently 
needs  just  such  a  work  as  this,  for  immediate  refe- 
rence in  moments  of  sudden  emergency,  when  he  has 
not  time  to  consult  more  elaborate  treatises. — Tke 
Ohio  Medical  and  Surgical  Journal. 

The  author  has  evidently  ransacked  every  stand- 
ard treatise  of  ancient  and  modern  times,  and  all  that 


is  really  practically  useful  at  the  bedside  will  be 
found  in  a  form  at  once  clear,  distinct,  and  interest- 
ing.—£d(»6  it  r^  A.  Monthly  Medical  Journal. 

Druitt's  work,  condensed,  systematic,  lucid,  and 
practical  as  it  is,  beyond  most  works  on  Surgery 
accessible  to  the  American  student,  has  had  much 
currency  in  this  country,  and  under  its  present  au- 
spices promises  to  rise  to  yet  higher  favor. — The 
Western  Journal  of  Medicine  and  Surgery. 

The  most  accurate  and  ample  resume  of  the  pre- 
sent state  of  Surgery  that  we  are  acquainted  with. — 
Dublin  Medical  Journal. 

A  better  book  on  the  principles  and  practice  of 
Surgery  as  now  understood  in  England  and  America, 
has  not  been  given  to  the  profession. — Boston  Medi- 
cal and  Surgical  Journal. 

An  unsurpassable  compendium,  not  only  of  Sur- 
gical, but  of  Medical  Practice. — London  Medical 
Gazette, 

This  work  merits  our  warmest  commendations, 
and  we  strongly  recommend  it  to  young  surgeons  as 
an  admirable  digest  of  the  principles  and  practice  of 
modern  Surgery. — Medical  Gazette. 

It  may  be  said  with  truth  that  the  work  of  Mr. 
Druitt  affords  a  complete,  though  brief  and  con- 
densed view,  of  the  entire  field  of  modern  surgery. 
We  know  of  no  work  on  the  same  subject  having  the 
appearance  of  a  manual,  which  includes  so  many 
topics  of  interest  to  the  surgeon  ;  and  the  terse  man- 
ner in  which  each  has  been  treated  evinces  a  most 
enviable  quality  of  mind  on  the  part  of  the  author, 
who  seems  to  have  an  innate  power  of  searching 
out  and  grasping  the  leading  facts  and  features  of 
the  most  elaborate  productions  of  the  pen.  It  is  a 
useful  handbook  for  the  practitioner,  and  we  should 
deem  a  teacher  of  surgery  unpardonable  who  did  not 
recommend  it  to  his  pupils.  In  our  own  opinion,  it 
is  admirably  adapted  to  the  wants  of  the  student. — 
Provincial  Medical  and  Surgical  Journal. 


DUNGLISON,    FORBES,    TWEEDIE,    AND    CONOLLY. 
THE  CYCLOPEDIA  OF  PRACTICAL  MEDICINE:  comprising  Treatises  on 

the  Nature  and  Treatment  of  Diseases,  Materia  Medica,  and  Therapeutics,  Diseases  of  Women 
and  Children,  Medical  Jurisprudence,  &:c.  5cc.  h\  four  large  super  royal  octavo  volumes,  of 
3254  double-columned  pages,  strongly  and  handsomely  bound. 

*,j(.*  This  work  contains  no  less  than  four  hundred  and  eighteen  distinct  treatises,  contributed  by 
sixty-eight  distinguished  physicians. 


The  most  complete  w^ork  on  Practical  Medicine  ' 
extant;  or,  at  least,  in  our  language. —  Buffalo 
Medical  and  Surgical  Journal.  ' 

For  reference,  it  is  above  all  price  to  ever)-  prac-  ' 
titioner. — Western  Lancet. 

One  of  the  most  valuable  medical  publications  of 
the  day — as  a  w^ork  of  reference  it  is  invaluable. — 
Western  Journal  of  Medicine  and  Surgery. 

It  has  been  to  us,  both  as  learner  and  teacher,  a 
work  for  ready  and  freqaent  reference,  one  in  which 
modern  English  medicine  is  exhibited  in  the  most 
advantageous  light. — Medical  Examiner. 

We  rejoice  that  this  work  is  to  be  placed  within 
the  reach  of  the  profession  in  this  country,  it  being 


unquestionably  one  of  very  great  value  to  the  prac- 
titioner. This  estimate  of  it  has  not  been  formed 
from  a  hasty  examination,  but  after  an  intimate  ac- 
quaintance derived  from  frequent  consultation  of  it 
during  the  past  nine  or  ten  years.  The  editors  are 
practitioners  of  established  reputation,  and  the  list 
of  contributors  embraces  many  of  the  most  eminent 
professors  and  teachers  of  London,  Edinburgh,  Dub- 
lin, and  Glasgow.  It  is,  indeed,  the  great  merit  of 
this  work  that  the  principal  articles  have  been  fur- 
nished by  practitioners  who  have  not  only  devoted 
especial  attention  to  the  diseases  about  which  they 
have  written,  but  have  also  enjoyed  opportunities 
for  an  extensive  practical  acquaintance  with  them, 
and  whose  reputation  carries  the  assurance  of  their 
competency  justly  to  appreciate  the  opinions  of 
others,  ■ivhile  it  stamps  their  o^vn  doctrines  with 
high  and  just  authority. — American  Medical  Journ. 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  the  Institutes  of  Medicine,  in  the  Jefferson  Medical  College,  Philadelphia. 

HUMAN  HEALTH;  or,  the  Influence  of  Atmosphere  and  Locality,  Change  of 

Air  and  Climate,  Seasons,  Food,  Clothing,  Bathing,  Exercise,  Sleep,  &c.  &c.,  on  Healthjr  Man; 
constituting  Elements  of  Hygiene.  Second  edition,  with  many  modifications  and  additions.  In 
one  octavo  volume,  of  464  pages. 


12 


BLANCHARD   &    LEA'S    MEDICAL 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

MEDICAL   LEXICON;   a  Dictionary  of  Medical  Science,  containins;  a  concise 

Explanation  of  the  various  Subjects  and  Terms  of  Physiology,  Pathology,  Hygiene,  Therapeutics, 
Pharmacology,  Obstetrics,  Medical  Jurisprudence,  &c.  With  the  French  and  other  Synonymes  ; 
Notices  of  Climate  and  of  celebrated  Mineral  Waters;  Formulse  for  various  Officinal,  Empirical, 
and  Dietetic  Preparations,  etc.  Eleventh  edition,  revised.  In  one  very  thick  octavo  volume,  of 
over  nine  hundred  large  double-columned  pages,  strongly  bound  in  leather,  with  raised  bands. 
(Just  Issued.) 

Every  successive  edition  of  this  work  bears  the  marks  of  the  industry  of  the  author,  and  of  his 
determination  to  keep  it  fully  on  a  level  with  the  most  advanced  state  of  medical  science.  Thus 
nearly  fifteen  thousand  words  have  been  added  to  it  within  the  last  few  years.  As  a  complete 
Medical  Dictionary,  therefore,  embracing  over  FIFTY  THOUSAND  DEFINITIONS,  in  all  the 
branches  of  the  science,  it  is  presented  as  meriting  a  continuance  of  the  great  favor  and  popularity 
which  have  carried  it,  within  no  very  long  space  of  time,  to  an  eleventh  edition. 

Every  precaution  has  been  taken  in  the  preparation  of  the  present  volume,  to  render  its  mecha- 
nical execution  and  typographical  accuracy  worthy  of  its  extended  reputation  and  universal  use. 
The  very  extensive  additions  have  been  accommodated,  without  materially  increasing  the  bulk  of 
the  volume  by  the  employment  of  a  small  but  exceedingly  clear  type,  cast  for  this  purpose.  The 
press  has  been  watched  with  great  care,  and  every  effort  used  to  insure  the  verbal  accuracy  so  ne- 
cessary to  a  work  of  this  nature.  The  whole  is  printed  on  fine  white  paper  ;  and,  while  thus  exhi- 
biting in  every  respect  so  great  an  improvement  over  former  issues,  it  is  presented  at  the  original 
exceedingly  low  price. 


We  welcome  it  cordially;  it  is  an  admirable  work, 
and  indispensable  to  all  literary  medical  men.  The 
labor  which  has  been  bestowed  upon  it  is  something 
prodigious.  The  work,  however,  has  now  been 
done,  and  we  are  hnppy  in  the  thought  that  no  hu- 
man being  will  have  again  to  undertake  the  same 
gigantic  task.  Revised  and  corrected  from  time  to 
time,  Dr.  Dunglison's  "  Medical  Lexicon"  will  last 
for  centuries. — British  and  Foreign  Med.  Chirurg. 
Review,  July,  1853. 

The  fact  that  this  excellent  and  learned  work  has 
passed  through  eight  editions,  and  that  a  ninth  is 
rendered  necessary  Jay  the  demands  of  the  public, 
affords  a  sufficient  evidence  of  the  general  apprecia- 
tion of  Dr.  Dunglison's  labors  by  the  medical  pro- 
fession in  England  and  America,  [t  is  a  book  which 
will  be  of  great  service  to  the  student,  in  teaching 
him  the  meaning  of  all  the  technical  terms  used  in 
medicine,  and  will  be  of  no  less  use  to  the  practi- 
tioner who  desires  to  keep  himself  on  a  level  with 
the  advance  of  medical  science. — London  Medical 
Times  and  Gazette. 

In  taking  leave  of  our  author,  we  feel  compelled 
to  confess  that  his  work  bears  evidence  of  almost 
incredible  labor  having  been  bestowed  upon  its  com- 
position.—  Edinburgh  Journal  of  Med.  Sciences, 
Sept.  1853. 

A  miracle  of  labor  and  industry  in  one  who  has 
written  able  and  voluminous  works  on  nearly  every 
branch  of  medical  science.  There  could  be  no  more 
useful  book  to  the  student  or  practitioner,  in  the 
present  advancing  age,  than  one  in  which  would  be 
found,  in  addition  to  the  ordinary  meaning  and  deri- 
vation of  medical  terms — so  many  of  which  are  of 
modern  introduction — concise  descriptions  of  their 
explanation  and  employment ;  and  all  this  and  much 
more  is  contained  in  the  volume  before  us.  It  is 
therefore  almost  as  indispensable  to  the  other  learned 
professions  as  to  our  own.  In  fact,  to  all  who  may 
hat'e  occasion  to  ascertain  the  meaning  of  any  word 
belonging  to  the  many  branches  of  medicine.  From 
a  careful  examination  of  the  present  edition,  we  can 
vouch  for  its  accuracy,  and  for  its  being  brought 
quite  up  to  the  date  of  publication  ;  the  author  states 
in  his  preface  that  he  has  added  to  it  about  four  thou- 
sand terms,  which  are  not  to  be  found  in  the  prece- 
ding one.  —  Dublin  Quarterly  Journal  of  Medical 
Sciences. 

On  the  appearance  of   the  last  edition  of  this 


valuable  work,  we  directed  the  attention  of  our 
readers  to  its  peculiar  merits;  and  we  need  do 
little  more  than  state,  in  reference  to  the  present 
reissue,  that,  notwithstanding  the  large  additions 
previously  made  to  it,  no  fewer  than  four  thou- 
sand terms,  not  to  be  found  in  the  preceding  edi- 
tion, are  contained  in  the  volume  before  us. — 
Whilst  it  is  a  wonderful  monument  of  its  author's 
erudition  and  industry,  it  is  also  a  work  of  great 
practical  utility,  as  we  can  testify  from  our  own 
experience;  for  we  keep  it  constantly  within  our 
reach,  and  make  very  frequent  Inference  to  it, 
nearly  always  finding  in  it  the  information  ■we  seek. 
— British  and  Foreign  Med.-Chirurg.  Review. 

It  has  the  rare  merit  that  it  certainly  has  no  rival 
in  the  English  language  for  accuracy  and  extent 
of  references.  The  terms  generally  include  short 
physiological  and  pathological  descriptions,  so  that, 
as  the  author  justly  observes,  the  reader  does  not 
possess  in  this  work  a  mere  dictionary,  but  a  book, 
which,  while  it  instructs  him  in  medical  etymo- 
logy, furnishes  him  with  a  large  amount  of  useful 
information.  The  author's  labors  have  been  pro- 
perly appreciated  by  his  own  countrymen  ;  and  we 
can  only  confirm  their  judgment,  by  recommending 
this  most  useful  volume  to  the  notice  of  our  cisat- 
lantic readers..  No  medical  library  will  be  complete 
without  it. — London  Med.  Gazette. 

It  is  certainly  more  complete  and  comprehensive 
than  any  with  which  we  are  acquainted  in  the 
English  language.  Few,  in  fact,  could  be  found 
better  qualified  than  Dr.  Dunglison  for  the  produc- 
tion of  such  a  work.  Learned,  industrious,  per- 
severing, and  accurate,  he  brings  to  the  task  all 
the  peculiar  talents  necessary  for  its  successful 
performance;  while,  at  the  same  time,  his  fami- 
liarity with  the  writings  of  the  ancient  and  modern 
"  masters  of  our  art,"  renders  him  skilful  to  note 
the  exact  usage  of  the  several  terras  of  science, 
and  the  various  modifications  which  medical  term- 
inology has  undergone  with  the  change  of  theo- 
ries or  the  progress  of  improvement.  —  American 
Journal  of  the  Medical  Sciences. 

One  of  the  most  complete  and  copious  known  to 
the  cultivators  of  medical  science. — Boston  Med. 
Journal. 

The  most  comprehensive  and  best  English  Dic- 
tionary of  medical,  terms  extant. — Buffalo  Medical 
Journal. 


BY   THE   SAME   AUTHOR. 

THE  PKACTICE  OF  MEDICINE.     A  Treatise  on  Special  Pathology  and  The- 
rapeutics.   Third  Edition.    In  two  large  octavo  volumes,  of  fifteen  hundred  pages. 

ferings  of  the  race. — Boston  Medical  and  Surgical 
Journal. 


Upon  every  topic  embraced  in  the  work  the  latest 
information  will  be  found  carefully  posted  up. — 
Medical  Exaininer. 

The  student  of  medicine  will  find,  in  these  two 
elegant  volumes,  a  mine  of  facts,  a  gathering  of 
precepts  and  .advice  from  the  world  of  experience, 
that  will  nerve  him  with  courage,  and  faithfully 
direct  him  in  his  efforts  to  relieve  the  physical  suf- 


It  is  certainly  the  most  complete  treatise  of  which 
we  have  any  knowledge. — Western  Journal  of  Medi- 
cine and  Surgery. 

One  of  the  most  elaborate  treatises  of  the  kind 
we  have. — Southern  Med.  and  Surg.  Journal. 


AND    SCIENTIFIC    PUBLICATIONS. 


13 


DUNGLISON    (ROBLEY),    M.D., 

Professor  of  Institutes  of  Medicine  in  the  Jefferson  Medical  College,  Philadelphia. 

HUMAN  PHYSIOLOG-Y.  Seventh  edition.  Thoroughly  revised  and  exten- 
sively modified  and  enlarged,  with  nearly  five  hundred  illustrations.  In  two  laro-e  and  hand- 
somely printed  octavo  volumes,  containing-  nearly  1450  pages. 

It  has  long;  since  taken  rank  as  one  of  the  medi-  j  Physiology  in  the  English  language,  and  is  highly 
cal  classics  of  our  language.     To  say  that  it  is  by     creditable  to  the  author  and  publishers.— Careadjore 
far  the  best  text-book  of  physiology  ever  published     Medical  Journal, 
in  this  countr\',   is  but  echoing   the  general  testi- 
mony of  the  profession. — N.  Y.  Journal  of  Medicine 


The  most  complete  and  satisfactory  system  of 
Physiology  in  the  English  language. — Amer.  Med. 
Journal. 

The  best  work  of  the  kind  in  the  English  lan- 
guage.— Sillitnan's  Journal. 

The  most  full  and  complete  system  of  Physiology 
in  our  language. — Western  Lancet. 


There  is  no  single  book  we  would  recommend  to 
the  student  or  physician,  wth  greater  ciinfidence  '• 
than  the  present,  because  in  it  will  be  found  a  rnir-  j 
rorof  almost  every  standard  physiological  work  of 
the  day.  We  most  cordially  recommend  the  work  | 
to  every  member  of  the  profession,  and  no  student  ' 
should  be  without  it.    It  is  the  completest  work  on  | 

BY    THE    SAME    AUTHOR.       {JtCSt  IssUed.) 

GENERAL    THERAPEUTICS    AND    MATERIA  MEDICA;   adapted  for  a 

Medical  Text-book.  Fifth  edition,  much  improved.  With  one  hundred  and  eighty-seven  illus- 
trations, iw  two  large  and  handsomely  prmted  octavo  vols.,  of  about  1100  pages. 
The  new  editions  of  the  United  States  Pharraacopogia  and  those  of  London  and  Dublin,  have  ren- 
dered necessary  a  thorough  revision  of  this  work.  In  accomplishing  this  the  author  has  spared  no 
pains  in  rendering  it  a  complete  exponent  of  all  that  is  new  and  reliable,  both  in  the  departments 
of  Therapeutics  and  Materia  Medica.  The  book  has  thus  been  somewhat  enlarged,  and  a  like  im 
provemeiit  will  be  found  in  every  department  of  its  mechanical  execution.  As  a  convenient  text- 
book for  the  student,  therefore,  containing  within  a  moderate  compass  a  satisfactory  resume  of  its 
important  subject,  it  is  again  presented  as  even  more  worthy  than  heretofore  of  the  very  great  favor 
which  it  has  received. 

In  this  work  of  Dr.  Dunglison,we  recognize  the        Asa  text-book  for  students,  for  ^vhom  it  is  par- 
same  untiring  industry  in  the  collection   and   em-     ticul.irly  designed,   ^ve    know  of   none   superior  to 
bodying  of  facts  on  the  several  subjects  of  which  he     it. — St.  Louis  Medical  and  Surgical  Journal. 
treats,  that  has  heretofore  distinguished  him,  and 


■we  cheerfully  point  to  these  volumes,  as  t\vo  of  the 
most  interesting  that  we  know  of.  In  noticing  the 
additions  to  this,  the  fourth  edition,  there  is  very 
little  in  the  periodical  or  annual  literature  of  the 
profession,  published  in  the  interval  which  has 
elapsed  since  the  issue  of  the  first,  that  has  escaped 
the  careful  search  of  the  author.  As  a  book  for 
reference,  it  is  invaluable. — Charleston  Med.  Jour- 
nal and  Review. 

It  may  be  said  to  be  the  work  now  upon  the  sub- 
jects upon  which  it  treats. —  Western  Lancet. 


It  purports  to  be  a  new  edition,  but  it  is  rather 
a  new  book,  so  greatly  has  it  been  improved,  both 
in  the  amount  and  quality  of  the  matter  which  it 
contains. — N.  O.  Medical  and  Surgical  Journal. 

We  bespeak  for  this  edition,  from  the  profession, 
an  increase  of  patronage  over  any  of  its  former 
ones,  on  account  of  its  increased  merit.  —  N.  Y. 
Journal  of  Medicine. 

We  consider  this  work  unequalled. — Boston  Med. 
and  Surg.  Journal. 


BY   THE   SAME   AUTHOR. 


NEW  REMEDIES,  WITH  FORMULA  FOR  THEIR  ADMINISTRATION. 

Sixth  edition,  with  extensive  Additions.     In  one  very  large  octavo  volume,  of  over  750  pages. 

One  of  the  most  useful  of  the  author's  works. —    diseases  and  for  remedies,  will  be  found  greatly  to 
Southern  Medical  and  Surgical  Journal.  enhance  its  value. — Neio  York  Med.  Gazette. 


This  well-known  and  standard  book  has  now 
reached  its  sixth  edition,  and  has  been  enlarged  and 
improved  by  the  introduction  of  all  the  recent  gifts 
to  therapeutics  which  the  last  few  years  have  so 
richly  produced,  including  the  anassthetie  agents, 
&c.  This  elaborate  and  useful  volume  should  be 
found  in  every  medical  librar)',  for  as  a  book  of  re- 
ference, for  physicians,  it  is  unsurpassed  by  any 
other  work  in  existence,  and  the  double  index  for 


The  great  learning  of  the  author,  and  his  remark- 
able industry  in  pushing  his  researches  into  every 
S')urce  whence  inforniiition  is  derivable,  has  enabled 
him  to  throw  together  an  e.'ctensive  mass  of  facts 
and  statements,  accompanied  by  full  reference  to 
authorities;  which  last  feature  renders  the  ^vork 
practically  valuable  to  investigators  who  desire  to 
examine  the  original  p.apers. — The  American  Journal 
of  Pharmacy. 


DURLACHEFl    (LEWIS). 
A  TREATISE    ON   CORNS,   BUNIONS,   THE    DISEASES    OF    NAILS, 

AND  THE  GENERAL  MANAGEMENT  OF  THE  FEET.    In  one  r2mo.  volume,  cloth. 
pp.  134. 


DE  JONGH  (L.  J.),  M.  D.,  Sec. 
THE  THREE  KINDS   OF  COD-LIVER  OIL,  comparatively  considered,  with 

their  Chemical  and  Therapeutic  Properties.  Translated,  with  an  Appendix  and  Cases,  by 
Edward  Carey,  M.  D.  To  which  is  added  an  article  on  the  subject  from  "Dunglison  on  New 
Remedies."    In  one  small  12mo.  volume,  extra  cloth. 


DAY  (GEORGE  E.),  M.  D. 
A  PRACTICAL  TREATISE  ON  THE  DOMESTIC  MANAGEMENT  AND 

MORE  IMPORTANT  DISEASES  OF  ADVANCED  LIFE.  With  an  Appendix  on  a  new 
and  successful  mode  ol  treating  Lumbago  and  other  forms  of  Chronic  Rheiunatisui.  One  volume 
octavo,  226  pages. 


14 


BLANCHARD    &   LEA'S    MEDICAL 


ELLIS  (BENJAMIN),  M.D. 
THE   MEDICAL   FORMULARY :   being  a  Collection  of  Prescriptions,  derived 

from  the  writings  and  practice  of  many  of  the  most  eminent  physicians  of  America  and  Europe. 
Together  with  the  usual  Dietetic  Preparations  and  Antidotes  for  Poisons.  To  which  is  added 
an  Appendix,  on  the  Endermic  use  of  Medicines,  and  on  the  use  of  Elher  and  Chloroform.  The 
whole  accompanied  with  a  few  brief  Pharmaceutic  and  Medical  Observations.  Tenth  edition, 
revised  and  much  extended  by  Robert  P.  Thomas,  M.  D.,  Professor  of  Materia  Medica  in  the 
Philadelphia  College  of  Pharmacy.  In  one  neat  octavo  volume,  of  two  hundred  and  ninety-six 
pages.    [Noiv  Ready.     Revised  and  enlarged  to  1854.) 

This  work  has  received  a  very  complete  revision  at  the,  hands  of  the  editor,  who  has  made  what- 
ever alterations  and  additions  the  progress  of  medical' and  pharmaceutical  science  has  rendered  ad- 
visable, introducing  fully  the  new  remedial  agents,  and  revising  the  whole  by  the  latest  improvements 
of  the  Pharmacopoeia.  To  accommodate  these  additions,  the  size  of  the  page  has  been  increased, 
and  the  volume  itself  considerably  enlarged,  while  every  eifort  has  been  made  to  secure  the  typo- 
graphical accuracy  which  has  so  long  merited  the  confidence  of  the  profession. 

After  an  examination  nf  the  new  matter  and  the 
alterations,  w^e  believe  the  reputation  of  the  work 


built  up  by  the  author,  and  the  late  distinfjuished 
editor,  will  continue  to  flourish  under  the  auspices 
of  the  present  editor,  ^vhohas  the  industry  and  accu- 
racy, and,  we  would  say,  conscientiousness  requi- 
site for  the  responsible  task. — American  Journal  of 
Pharmacy,  March,  1854. 


It  ■will  prove  particularly  useful  to  students  and 
young  priictitioners,  as  the  most  important  prescrip- 
tions employed  in  modern  practice,  which  lie  scat- 
tered through  our  medical  literature,  are  here  col- 
lected and  conveniently  arranged  for  reference. — 
Charleston  Med.  Journal  and  Review. 


ERICHSEN    (JOHN)., 

Professor  of  Surgery  in  University  College,  London,  &;c. 

THE  SCIENCE  AND  ART  OF  SURQERY;  being  a  Treatise  on  Surgical 

Injuries,  Diseases,  and  Operations.     With  Notes  and  Additions  by  the  American  Editor.     Il- 
lustrated with  over  three  hundred  engravings  on  wood.     In  one  large  and  handsome  octavo 
volume,  of  nearly  nine  hundred  closely  printed  pages.    {Now  Ready .) 
This  is  a  new  work,  brought  up  to  May,  18-54. 
This  work,  w^hich  is  designed  as  a  text-book  for  the  student  and  practitioner,  will  be  found  a  very 
complete  treatise  on  \\ie  principles  and  practice  of  surgery.     Embracing  both  these  branches  of  the 
subject  simultaneously,  and  elucidating  the  one  by  the  other,  it  enables  the  reader  to  take  a  compre- 
hensive view  of  the  objects  of  his  study,  and  presents  the  subjects  discussed  in  a  clear  and  con- 
nected manner.     The  author's  style  will  be  found  easy  and  flowing,  and  the  illustrations  having 
been  drawn  under  his  especial  supervision,  are  with  few  exceptions  new,  and  admirably  adapted 
to  elucidate  the  text  to  which  they  refer.     In  every  point  of  mechanical  execution,  it  will  be  one  of 
the  handsomest  works  issued  from  the  American  press. 


The  aim  of  Mr.  Erichsen  appears  to  he  to  improve 
upon  the  plan  of  Samuel  Cooper;  and  by  connecting 
in  one  volume  the  science  and  art  of  Surgery,  to 
supply  the  student  with  a  text-book  and  the  practi- 
tioner with  a  work  of  reference,  in  which  scientific 
principles  and  practical  details  are  alike  included. 
"We  may  say,  afier  a  careful  perusal  of  some  of 
the  chapters,  and  a  more  hasty  examination  of  the 
remainder,  that  it  must  raise  the  character  of  the 
author,  and  reflect  great  credit  upon  the  College  to 


which  he  is  Professor,  and  ^ve  can  cordially  recom- 
mend it  as  a  work  of  reference,  both  to  students  and 
practitioners. — Medical  Times  and  Gazette. 

"We  do  not  hesitate  to  say  that  the  volume  before 
us  gives  a  very  admirable  practical  vie^v  of  the  sci- 
ence and  art  of  surgery  of  the  present  day,  and  we 
have  no  doubt  that  it  will  be  highly  valued  as  a  sur- 
gical guide  as  well  by  the  surgeon  as  by  the  student 
of  surgery. — Edinburgh  Med.  and  Surg.  Journal. 


FERGUSSON  (WILLIAM),  F.  R.  S., 

Professor  of  Surgery  in  King's   College,  London,  &c. 

A  SYSTEM  OF  PRACTICAL  SURGERY.     Fourth  American,  from  the  third 

and  enlarged  London  edition.     In  one  large  and  beautifully  printed  octavo  volume,  of  about  seven 
hundred  pages,  with  three  hundred  and  ninety-three  handsome  illustrations.     (Just  Issued.) 


The  most  important  subjects  in  connection  with 
practical  surge-ry  which  have  been  move  recently 
brought  under  the  notice  of,  and  discussed  by,  the 
surgeons  of  Great  Britain,  are  fully  and  dispassion- 
ately considered  by  Mr.  FerguSson,  and  that  which 
was  before  wanting  has  now  been  supplied,  so  that 
we  can  now  look  upon  it  as  a  work  on  practical  sur- 
gery instead  of  one  on  operative  surgery  alone.  And 
we  think  the  author  has  shown  a  wise  discretion  in 
making  the  additions  on  surgical  disease  which  are 
to  be  found  in  the  present  volume,  and  has  very 
much  enhanced  its  value;  for,  besides  two  elaborate 
chapters  on  the  diseases  of  bones  and  joints,  which 
were  wanting  before,  he  has  headed  each  chief  sec- 
tion of  the  work  by  a  general  description  of  the  sur- 
gical disease  and  injury  of  tliat  region  of  the  body 
which  is  treated  of  in  each,  prior  to  entering  into  the 
consideration  of  the  more  special  morbid  conditions 
and  their  treatment.  There  is  also,  as  in  former 
editions,  a  sketch  of  the  anatomy  of  particular  re- 
gions. There  was  some  ground  formerly  for  the 
complaint  before  alluded  to,  that  it  dwelt  too  exclu- 


sively on  operative  surgery  ;  but  this  defect  is  now 
removed,  and  the  book  is  more  than  ever  adapted  for 
the  purposes  of  the  practitioner,  whether  he  confines 
himself  more  strictly  to  the  operative  department, 
or  follows  surgery  on  a  more  comprehensive  scale. — 
Medical  Times  and  Gazette. 

No  work  was  ever  written  which  more  nearly 
comprehended  the  necessities  of  tlie  student  and 
practitioner,  and  was  more  carefully  arranged  to 
that  single  purpose  than  this. — N.  Y.  Med.  and  Surg. 
Journal. 

The  addition  of  many  new  pages  makes  this  work 
more  than  ever  indispensable  to  the  student  and  prac- 
titioner.— Ranking's  Abstract. 

Among  the  numerous  works  upon  surgery  pub- 
lished of  late  years,  we  know  of  none  we  value 
more  highly  than  the  one  before  us.  It  is  perhaps 
the  very  best  we  have  for  a  text-book  and  for  ordi- 
nary reference,  being  concise  and  eminently  practi- 
cal.—SoM«/iern.  Med.  and  Surg.  Journal. 


FRICK  (CHARLES),  M.  D. 
RENAL    AFFECTIONS;    their  Diagnosis  and  Pathology. 

One  volume,  royal  12mo.,  extra  cloth. 


With  illustrations. 


AND    SCIENTIFIC    PUBLIC ATIONa. 


15 


FOWNES  (GEORGE),   PH.  D.,  &.c. 
ELEMENTARY    CHEMISTRY;    Theoretical  and  Practical.     With  numerous 

illustrations.  A  new  American,  from  the  last  and  revised  London  edition.  Edited,  with  Addi- 
tions, by  Robert  Bridges,  M.  D.  In  one  large  royal  12mo.  volume,  of  over  550  pages,  with  181 
wood-cuts,  sheep,  or  extra  cloth.     {Noiv  Ready.) 

The  lamented  death  of  the  auihor  has  caused  the  revision  of  this  edition  to  pass  into  the  hands  of 
inose  distuigfuished  chemists,  H.  Bence  Jones  and  A.  W.  Hofmann,  who  have  fully  sustained  its 
reputation  by  the  additions  whicb  they  have  made,  more  especially  in  the  portion  devoted  to  Organic 
Chemistry,  considerably  increasing  the  size  of  the  volume.  This  labor  has  been  so  Ihoroushly 
performed,  that  the  American  Editor  has  found  but  little  to  add,  his  notes  consisting  chiefly  of  sucii 
matters  as  the  rapid  advance  of  the  science  has  rendered  necessary,  or  of  investigations  which  had 
apparently  been  overlooked  by  the  author's  friends. 

The  volume  is  therefore  again  presented  as  an  exponent  of  the  most  advanced  state  of  chemical 
science,  and  as  not  unworthy  a  continuation  of  the  marked  favor  which  it  has  received  as  an  ele- 
mentary text-book. 


^Ve  know  of  no  better  text- book,  especiiilly  in  the 
difficult  department  of  organic  chemistry,  upon 
which  it  is  purticularly  full  and  satisfactory.  We 
\vould  recommend  it  to  preceptors  as  a  capital 
"  office  book"  for  their  students  who  are  beginners 
in  Chemistry.  It  is  copiously  illustrated  with  ex- 
cellent "svood-cuts,  and  altogether  admirably  "got 
up." — N.  J.  Medical  Reporter,  March,  165-1. 

A  standard  manual,  which  has  long  enjoyed  the 
reputation  of  embodying  much  knowledarein  a  small 
space.  The  author  has  achieved  the  difficult  task  of 
condensation  with  masterly  tact.     His  book  is  eon- 


The  work  of  Dr.  Fownes  has  lon^r  been  before 
the  public,  and  its  merits  have  been  fully  appreci- 
ated as  the  best  text-book  on  chemistry  now  in 
existence.  We  do  not,  of  course,  place  it  in  a  rank 
superior  to  the  ■works  of  Brande,  Graham,  Turner, 
Gregory,  or  Gmelin,  but  we  say  that,  as  a  \vorJc 
for  students,  it  is  preferable  to  any  of  them. — Lon- 
don Journal  of  Medicine. 

A  work  well  adapted  to  the  ^vants  of  the  student. 
It  is  an  excellent  exposition  of  the  chief  doctrines 
and  facts  of  modern  chemistry.  The  size  of  the  work, 
and  still  more  the  condensed  yet  perspicuous  style 


cise  without  being  dry,  and  brief  without  being  too  I  in  -which  it  is  written,  absolve  it  from  the  charges 
dogmatical  or  general. —  Virginia  Med.  and  Surgical  \  very  properly  urged  against  most  manuals  termed 
Journal.  popular. — Edinburgh,  Monthly  Journal  of  Meiical 

'  Science. 


GRAHAM   (THOMAS),   F.  R.  S., 

Professor  of  Chemistry  in  University  College,  London,  &c. 

THE  ELEMENTS  OF  CHEMISTRY.     Including  the  application  of  the  Science 

to  the  Arts.    With  numerous  illustrations.    With  Notes  and  Additions,  by  Robert  Bridges, 
M.  D.,  &c.  &c.     Second  American,  from  the  second  and  enlarged  London  edition 
PART  I.  (Lately  Issued)  large  8vo.,  430  pages,  1S5  illustrations. 
PART  II.  {Preparing)  to  match. 

The  great  changes  which  the  science  of  chemistry  has  undergone  within  the  last  few  years,  ren- 
der a  new  edition  of  a  treatise  like  the  present,  almost  a  new  work.  The  author  has  devoted 
several  years  to  the  revision  of  his  treatise,  and  has  endeavored  to  embody  in  it  every  fact  and 
inference  of  importance  which  has  been  observed  and  recorded  by  the  great  body  of  chemical 
investigators  who  are  so  rapidly  changing  the  face  of  the  science.  In  this  manner  the  work  has 
been  greatly  increased  in  size,  and  the  number  of  illustrations  doubled  ;  while  the  labors  of  the  editor 
have  been  directed  towards  the  introduction  of  such  matters  as  have  escaped  the  attention  of  the 
author,  or  as  have  arisen  since  the  publication  of  the  first  portion  of  this  edition  in  London,  in  1850. 
Printed  in  handsome  style,  and  at  a  very  low  price,  it  is  therefore  confidently  presented  to  the  pro- 
fession and  the  student  as  a  very  complete  and  thorough  text-book  of  this  important  subject. 


GROSS  (SAMUEL  D.)j   M.  D., 

Professor  of  Surgery  in  the  Louisville  Medical  Institute,  &c. 

A  PRACTICAL  TREATISE  ON  THE  DISEASES  AND  INJURIES   OF 

THE  miNARY  OR.GANS.     In  one  large  and  beautifully  printed  octavo  volume,  of  over  seven 
hundred  pages.     With  numerous  illustrations. 

A  volume  replete  with  truths  and  principles  of  the  f  this  department  of  art.  We  have,  indeed,  unfeigned 
utmost  value  in  the  investigation,  of  these  diseases. —  pleasure  in  congratulating  all  concerned  in  this  pub- 
American  Medical  Journal.  lication,  on  the  resultof  their  labours;  and  expe- 

Dr.  Gross  has  brought  all  his  learning,  experi-  rience  a  feeling  something  like  whatanimates  a  loug- 
ence,  tact,  and  judgment  to  the  task,  and  has  pro-  expe<^tant  liusbandman.who,oftentimesdisappointed 
duced  a  work  worthy  of  his  high  reputation.  We  1  by  the  produce  of  a  favorite  field,  is  at  last  agree- 
feel  perfectly  safe  in  recommending  it  to  our  rend-  i  ably  surprised  by  a   stately  crop  which   niay  hear 


perfectly  sate  in  recommending 
ers  as   a   monograph    unequalled    in    interest  and 
practical  value  by  any  other  on  the  subject  in  our 
language. — Western  Journal  of  Med.  and  Surg. 

It  has  remained  for  an  American  writer  to  -wipe 
away  this  reproach  j  and  so  completely  has  the  task 
been  fulfilled,  that  we  venture  to  predict  for  Dr. 
Gross's  treatise  a  permanent  place  in  the  literature 
of  surgery,  worthy  to  rank  with  the  best  works  of 


comparison  with  any  of  its  former  rivals.  The 
grounds  of  our  high  appreciation  of  the  work  will 
be  obvious  as  \ve  proceed  ;  and  we  doubt  not  that 
the  present  facilities  for  obtaining  American  books 
^vill  induce  many  of  our  readers  to  verit'y  our  re- 
commendation by  their  own  perusal  of  it. — British 
and  Foreign  Medico-Chirurgical  Review. 

Whoever  will  peruse  the  vast  amount  of  valuable 
the  present  age.  Not  merely  is  the  matter  good,  '  practical  information  it  contains,  and  wliich  we 
but  the  getting  up  of  the  volume  is  most  creditable  have  been  unable  even  to  notice,  will,  we  think, 
to  transatlantic  enterprise;  the  paper  and  print  agree  M'ith  us,  that  there  is  no  work  in  the  English 
vt'ould  do  credit  to  a  first-rate  London  establishment ;  language  which  can  make  anv  just  pretensions  to 
and  the  numerous  ^vood-cuts  which  illustrate  it,  de-  be  its  equal. — N.  V.  Journal  of  Medicine, 
monstrate  that  America  is  making  rapid  advances  in  , 

BY  THE  SAME  AUTHOR.     (In  Press.) 

A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE  AIR-PAS- 

SAGES.     In  one  handsome  octavo  volume,  with  illustrations. 

BY  THE  SAME  AUTHOR.     (Preparing.) 

A  SYSTEM  OF  SURGERY ;  Diagnostic,  Pathological,  Therapeutic,  and  Opera- 
tive.   "With  very  numerous  engravings  on  wood. 


16 


BLANCHARD   &    LEA'S   MEDICAL 


GLUGE  (GOTTLIEB),   M.D., 

Professor  of  Physiology  and  Pathological  Anatomy  in  the  University  of  Brussels,  &c. 

AN  ATLAS   OF   PATHOLOaiCAL   HISTOLOaY.     Translated,  with  Notes 

and  Additions,  by  Joseph  Leidy,  M.  D.,  Professor  of  Anatomy  in  the  University  of  Pennsylva- 
nia. In  one  volume,  very  large  imperial  quarto,  with  three  hundred  and  twenty  figures,  plain 
and  colored,  on  twelve  copperplates. 

the  unconnected  observations  of  a  great  number  of 
authors.  The  development  of  the  morbid  tissues, 
and  the  formation  of  abnormal  products,  may  now 
be  followed  and  studied  with  the  same  ease  and 
satisfaction  as  the  best  arranged  system  of  phy- 
siology.— American  Med.  Journal. 


This  being,  as  far  as  we  know,  the  only  work  in 
which  pathological  histology  is  separately  treated 
of  in  a  comprehensive  manner,  it  will,  we  think,  for 
this  reason,  be  of  infinite  service  to  those  who  desire 
to  investigate  the  subject  systematically,  and  who 
have  felt  the  difficulty  of  arranging  in   their  mind 


GRIFFITH  (ROBERT   E.),   M.  D.,  &.c. 

»A  UNIVERSAL  FORMULARY,  containing  the  methods  of  Preparing  and  Ad- 
ministering Officinal  and  other  Medicines.  The  whole  adapted  to  Physicians  and  Pharmaceu- 
tists. Second  Edition,  thoroughly  revised,  with  numerous  additions,  by  Robert  P.  Thomas, 
M.  D.,  Professor  of  Materia  Medica  in  the  Philadelphia  College  of  Pharmacy.  In  one  large  and 
handsome  octavo  volume,  of  over  six  hundred  pages,  double  columns.     (Just  Read-i/.) 

The  speedy  exhaustion  of  a  large  edition,  and  the  demand  for  a  second,  sufficiently  showthe  posi- 
tion which  this  work  has  so  rapidly  attained  as  an  authoritative  and  convenient  work  of  reference  for 
the  physician  and  pharmaceutist.  The  opportunity  thus  afforded  for  its  improvement  has  not  been 
neglected.  In  its  revision.  Professor  Thomas  (to  whom  this  task  has  been  confided  in  consequence 
of  the  death  of  the  author),  has  spared  no  labor,  in  the  hope  of  rendering  it  the  most  complete  and 
correct  work  on  the  subject  as  yet  presented  to  the  profession.  All  the  newly  introduced  articles 
of  the  Materia  Medica  have  been  inserted,  such  formulas  as  had  escaped  the  attention  of  the  author 
have  been  added,  and  the  whole  has  been  most  carefully  read  and  examined,  to  insure  the  absolute 
correctness,  so  indispensable  in  a  work  of  this  nature.  The  amount  of  these  additions  may  be  esti- 
mated from  the  fact  that  not  only  has  the  page  been  considerably  enlarged,  but  the  volume  has  also 
been  increased  by  about  fifty  pages,  while  the  arrangement  of  the  formulee  and  the  general  typo- 
graphical execution  will  be  found  to  have  undergone  great  improvement.  To  the  practitioner,  its 
copious  collection  of  all  the  forms  and  combinations  of  the  articles  of  the  Pharmacopoeia  render  it 
an  invaluable  book  of  reference,  while  its  very  complete  embodiment  of  officinal  preparations  of  all 
kinds,  derived  froni  all  sources,  American,  English,  and  Continental,  make  it  an  indispensable  assist- 
tant  to  the  apothecary. 


Dr.  Griffith's  Formulary  is  worthy  of  recommen- 
dation, not  only  on  account  of  the  care  which  has 
been  bestowed  on  it  by  its  estimable  author,  but  for 
its  general  accuracy,  and  the  richness  of  its  details. 
— Medical  Examiner. 

Most  cordially  we  recommend  this  Universal 
Formulary,  not  forgetting  its  adaptation  to  drug- 
gists and  apothecaries,  who  would  find  themselves 
vastly  improved  by  a  familiar  acquaintance  w^ith 
this  every-day  book  of  medicine. — The  Boston  Med. 
and  Surg.  Journal. 

A  very  useful  Avork,  and  a  most  complete  compen- 
dium on  the  subject  of  materia  medica.  We  know 
of  no  work  in  our  lang-uage,  or  any  other,  so  com- 
prehensive in  all  its  details. — London  Lancet. 


Pre-eminent  among  the  best  and  most  useful  com- 
pilations of  the  present  day  will  be  found  the  work 
before  us,  whicli  can  have  been  produced  only  at  a 
very  great  cost  of  thought  and  labor.  A  short  de 
scription  will  suffice  to  show  that  we  do  not  put 
too  high  an  estimate  on  this  work.  We  are  not  cog- 
nizant of  the  existence  of  a  parallel  work.  Its  value 
will  be  apparent  to  our  readers  from  the  sketch  of 
its  contents  above  given.  We  strongly  recommend 
it  to  all  who  are  engaged  either  in  practical  medi- 
cine, or  more  exclusively  with  its  literature. — Land. 
Med.  Gazette. 

A  valuable  acquisition  to  the  medical  practitioner, 
and  a  useful  book  of  reference  to  the  apothecary  on 
numerous  occasions. — Amer.  Journal  of  Pharmacy. 


BY   THE  SAME   AUTHOR. 

MEDICAL  BOTANY;  or,  a  Description  of  all  the  more  important  Plants  used 

in  Medicine,  and  of  their  Properties,  Uses,  and  Modes  of  Administration.     In  one  large  octavo 
volume,  of  704  pages,  handsomely  printed,  with  nearly  350  illustrations  on  wood. 

One  of  the  few  l)ooks  which  supply  a  positive  de- 
ficiency in  our  medical  literature. — Western  Lancet. 

We  hope  the  day  is  not  distant  when  this  work 
will  not  only  be  a  text-book  in  every  medical  school 
and  college  in  the  Union,  but  find  a  place  in  the  li- 
brary of  every  private  practitioner. — N.  Y.  Journal 
of  Medicine, 


One  of  the  greatest  acquisitions  to  American  medi- 
cal literature.  It  should  l)y  all  means  be  introduced, 
at  the  very  earliest  period,  into  our  medical  schools, 
and  occupy  a  place  in  the  library  of  every  physician 
in  the  land. — South-western  Medical  Advocate. 

Admirably  calculated  for  the  physician  and  stu- 
dent —  we  have  seen  no  work  which  promises 
greater  advantages  to  the  profession. — JV.  O.  Med. 
and  Surg.  Journal. 


LETTERS 


GREGORY  (WILLIAM),   F.  R.  S.  E., 

Professor  of  Chemistry  in  the  University  of  Edinburgh,  &c. 

TO  A  CANDID    INQUIRER    ON    ANIMAL    MAGNETISM. 


Description  and  Analj^sis  of  the  Phenomena.     Details  of  Facts  and  Cases.    In  one  neat  volume, 
royal  r2mo.,  extra  cloth. 


GARDNER  (D.  PEREIRA),  M.  D. 
MEDICAL  CHEMISTRY,  for  the  use  of  Students  and  the  Profession :  being  a 

Manual  of  the  Science,  with  its  Applications  to  Toxicology,  Physiology,  Therapeutics,  Hygiene, 
&e.    In  one  handsome  royal  I'^Jmo.  volume,  with  illustr»*ions. 


AND    SCIENTIFIC    PUBLICATIONS.  17 

HA-SSE  (C.  EJ,   M.  D. 
AN  ANATOMICAL  DESCRIPTION  OF  THE  DISEASES  OF  EESPIEA- 

TION  AND  CIRCULATION.     Translated  and  Edited  by  Swaine.    la  one  volume,  octavo. 


HARRISON  (JOHN),   M.D. 
AN   ESSAY  TOWARDS  A  CORRECT  THEORY  OF  THE  NERVOUS 

SYSTEM.    In  one  octavo  volume,  292  pages. 


HUNTER   (JOHN), 
TREATISE  ON  THE  VENEREAL  DISEASE.     With  copious  Additions,  by 

Dr.  Ph.  Ricord,  Surgeon  to  the  Venereal  Hospital  of  Paris.     Edited,  with  additional  Notes,  by 
F.  J.  BuMSTEAD,  M.  D.     In  one  octavo  volume,  with  plates.    {Norv  Ready.)     Sy  See  Ricord. 
Also,  HUNTER'S  COIPLETE  WORKS,  with  Memoir,  Notes,  &c.  &c.     In  four  neat  octavo 
volumes,  with  plates. 

HUGHES    (H.    M.),  M.  D., 

Assistant  Physician  to  Guy's  Hospital,  &c. 

A  CLINICAL  INTRODUCTION   TO  THE   PRACTICE   OF  AUSCULTA- 

TIOX;  and  other  Modes  of  Physical  Diagnosis,  in  Diseases  of  the  Lungs  and  Heart.     Second 
American  from  the  Second  and  Improved  London  Edition.  In  one  royal  ]2mo.  vol.  [Ju^t  Ready.) 
It  has  been*  carefully  revised  throughout.     Some  small  portions  have  been  erased ;  much  has 
been,  I  trust,  amended;  and  a  great  deal  of  new  matter  has  been  added;  so  that,  though  funda- 
mentally it  is  the  same  book,  it  is  in  many  respects  a  new  work. — Preface. 


HORNER  (WILLIAM  E.),  M.  D., 

Professor  of  Anatomy  in  the  University  of  Pennsylvania. 

SPECIAL    ANAT03IY    AND    HISTOLOGY.     Eighth  edition.     Extensively 

revised  and  modified.    In  two  large  octavo  volumes,  of  more  than  one  thousand  pages,  hand- 
somely printed,  with  over  three  hundred  illustrations. 

This  work  has  enjoyed  a  thorough  and  laborious  revision  on  the  part  of  the  author,  with  the 
view  of  bringing  it  full)-  up  to  the  existing  state  of  knowledge  on  the  subject  of  general  and  special 
anatomy.  To  adapt  it  more  perfectly  to  the  wants  of  the  student,  he  has  introduced  a  large  number 
of  additional  wood-engravmgs,  illustrative  of  the  objects  described,  while  the  publishers  have  en- 
deavored to  render  the  mechanical  execution  of  the  work  worthy  of  the  extended  reputation  which 
it  has  acquired.  The  demand  which  has  carried  it  to  an  EIGHTH  EDITION  is  a  sufficient  evi- 
dence of  the  value  of  the  work,  and  of  its  adaptation  to  the  wants  of  the  student  and  protessional 
reader. 

HOBLYN   (RICHARD  D.),  A.  M. 
A  DICTIONARY  OF  THE  TERMS  USED  IN  MEDICINTE  AND  THE 

COLLATERAL   SCIENCES.     Second  and  Improved  American  Edition.     Revised,  with  nu- 
merous Additions,  from  the  second  London  edition,  by  Isaac  Hays,  M.  D.,iSrc.     In  one  large 
royal  12mo.  volume,  of  over  four  hundred  pages,  double  columns.     [Nearly  Ready.) 
In  passing  this  work  a  second  time  through  the  press,  the  editor  has  subjected  it  to  a  very  tho- 
rough revision,  making  such  additions  as  the  progress  of  science  has  rendered  desirable,  and  sup- 
plying an}-  omissions  that  may  have  previously  existed.     As  a  concise  and  convenient  Dictionary 
of  Medical  Terms,  at  an  exceedingly  low  price,  it  will  therefore  be  found  of  great  value  to  the  stu- 
dent and  practitioner. 

HOPE  (J.),   M.  D.,  F.  R.  S.,  &.C. 
A  TREATISE  ON  THE   DISEASES    OP   THE    HEART   AND   GREAT 

VESSELS.     Edited  by  PE^■^•0CK.     In  one  volume,  octavo,  with  plates,  572  pages. 

HERSCHEL   (SIR   JOHN    F.  W.),  F.  R.  S.,  &.C. 
OUTLINES  OF  ASTRONOMY.     New  American,  from  the  third  London  edition. 

In  one  neat  volume,  crown  octavo,  with  six  plates  and  numerous  wood-cuts.     {Just  Issued.) 


HUMBOLDT  (ALEXANDER). 
ASPECTS  OF   NATURE    IN   DIFFERENT  LANDS    AND  DIFFERENT 

CLIMATES.     Second  American  edition,  one  vol.  royal  12mo  ,  extra  cloth. 


JONES  (T.  WHARTON),   F.  R.  S.,  &c. 
THE  PRINCIPLES  AND  PRACTICE  OF   OPHTHALMIC    MEDICINE 

AND  SURGERY.    Edited  by  Isaac  Hats,  M.  D.,  &c.     In  one  very  neat  volume,  large  royal 
12mo.,  of  529  pages,  with  four  plates,  plain  or  colored,  and  ninety-eight  wood-cuts. 


The  work  amply  sustains,  in  every  point  the  al- 
ready high  reputation  of  the  author  as  an  ophthalmic 
surgeon  as  well  as  a  physioloafist  and  pathologist. 
The  book  is  evidently  the  result  of  much  labor  and 
research,  and  has  been  ^vritten  ■with  the  greatest 
care  and  attention.  We  entertain  little  doubt  that 
this  book  will  become  what  its  author  hoped  it 


might  become,  a  manual  for  daily  reference  and 
consultation  by  the  student  and  the  general  practi- 
tioner. Tlie  work  is  marked  by  that  correctness, 
clearness,  and  precision  of  style  which  distinguish 
all  the  productions  of  the  learned  author. — British 
and.  Foreign,  Medical  Review. 


18 


BLANCHARD    Sc   LEA'S   MEDICAL 


JONES  (C.  HANDFIELD),  F.  R.  S.,   &.    EDWARD    H.  SIEVEKING,  M.  D. 
A  MANUAL  OF  PATHOLOGICAL  ANATOMY.     With  numerous  engravings 

on  wood.    In  one  handsome  volume.     (Preparing.) 


KIRKES  (WILLIAM   SENHOUSE),    M.  D., 

Demonstrator  of  Morbid  Anatomy  at  St.  Bartholomew's  Hospital,  &c.;  and 

JAMES   PAGET,  F.  R.  S., 

[/ecturer  on  General  Anatomy  and  Physiology  in  St.  Bartholomew's  Hospital. 

A    MANUAL    OP    PHYSIOLOGY.     Second  American,  from  the  second  and 

improved  London  edition.    With  one  hundred  and  sixty-five  illustrationi?.     In  one  large  and 
handsome  royal  12nio.  volume,     pp.550.     (Just  Issued.) 


In  the  present  edition,  the  Manual  of  Physiology 
has  been  brought  up  to  the  actual  condition  of  the 
science,  and  fully  sustains  t!ie  reputation  which  it 
has  already  so  deservedly  attained.  We  consider 
the  work  of  MM.  Kirkes  and  Paget  to  constitute  one 
of  the  very  best  handbooks  of  Physiology  we  possess 
— presenting  just  such  an  outline  of  the  science,  com- 
prising an  account  of  its  leading  facts  and  generally 
admitted  principles,  as  the  student  requires  during 
his  attendance  upon  a  course  of  lectures,  or  for  re- 
ference vvliilst  preparing  for  examination.  The  text 
is  fully  and  ably  illustrated  by  a  series  of  very  supe- 
rior wood-engravings,  by  which  a  comprehension  of 
some  of  the  more  intricate  of  the  subjects  treated  of 
is  greatly  facilitated. — Am.  Medical  Journal. 

We  need  only  say,  that,  without  entering  into  dis- 
cussions of  unsettled  questions,  it  contains  all  the 
recent  improvements  in  this  department  of  medical 
science.  For  the  student  beginning  this  study,  and 
the  practitioner  who  has  but  leisure  to  refresh  his 
memory,  this  book  is  invaluable,  as  it  contains  all 


that  it  is  important  to  know,  without  special  details, 
which  are  read  with  interest  only  by  those  who 
would  make  a  specialty,  or  desire  to  possessa  criti- 
cal knowledge  of  the  subject. — Charleston  Medical 
Journal. 

One  of  the  best  treatises  that  can  be  put  into  the 
hands  of  the  student. — London  Medical  Gazette. 

The  general  favor  with  which  the  first  edition  of 
this  work  was  received,  and  its  adoption  as  a  favor- 
ite text-book  by  many  of  our  colleges,  will  insure  a 
large  circulation  to  this  improved  edition.  It  will 
fully  meet  the  wants  of  the  student.  —  Southern 
Med.  and  Surg.  Journal. 

Particularly  adapted  to  those  who  desire  to  pos- 
sess a  concise  digest  of  the  facts  of  Human  Physi- 
ology.— British  and  Foreign  Med.-Chirurg.  Review. 

We  conscientiously  recommend  it  as  an  admira- 
ble "Handbook  of  Physiology." — London  Journal 
of  Medicine. 


KNAPP  (F.),  PH.  D.,  8ic. 
TECHNOLOGY ;  or,  Chemistry  applied  to  the  Arts  and  to  Manufactures,    Edited, 

with  numerous  Notes  and  Additions,  by  Dr.  Edmund  Ronalds  and  Dr.  Thobias  Richardson. 
First  American  edition,  with  Notes  and  Additions,  by  Prof.  Walter  R.  Johnson.  In  two  hand- 
some octavo  volumes,  printed  and  illustrated  in  the  highest  style  of  art,  with  about  five  himdred 

wood-engravings. 


LEHMANN. 
PHYSIOLOGICAL    CHEMISTRY.     Translated  by  George  E.  Day,  M.  D. 

(Preparing. ) 


LEE  (ROBERT),   M.  D.,  F.  R.  S.,  &c. 
CLINICAL    MIDWIFERY;    comprising  the   Histories  of  Five  Hundred  and 

Forty-five  Cases  of  Difficult,  Preternatural,  and  Complicated  Labor,  with  Commentaries.    From 
the  second  London  edition.     In  one  royal  12mo.  volume,  extra  cloth,  of  238  pages. 


LA    ROCHE   (R.),    M.  D.,  &,c. 

PNEUMONIA ;  its  Supposed  Connection,  Pathological  and  Etiological,  with  Au- 
tumnal Fevers,  including  an  Inquiry  into  the  Existence  and  Morbid  Agency  of  Malaria.  In  one 
handsome  octavo  volume,  extra  cloth,  of  500  pages. 


A  more  simple,  clear,  and  forcible  exposition  of 
the  groundless  nature  and  dangerous  tendency  of 
certain  pathological  and  etiological  heresies,  has 
seldom  been  presented  to  our  notice. — N.  Y.  Journal 
of  Medicine  and  Collateral  Science,  March,  1854. 

This  work  should  be  carefully  studied  by  Southern 
physicians,  embodying  as  it  does  the  reflecticms  of 
an  original  thinker  and  close  observer  on  a  subject 
peculiarly  their  own. —  Virginia  Med.  and  Surgical 
Journal. 

The  author  had  prepared  us  to  expect  a  treatise 
from  him,  by  his  brief  papers  on  kindred  topics  in 


the  periodical  press,  and  yet  in  the  w^ork  before  us 
he  has  exhibited  an  amount  of  industry  and  learning, 
research  and  ability,  beyond  what  we  are  accustomed 
to  discover  in  modern  medical  writers;  while  his 
own  extensive  opportunities  for  observation  and 
experience  have  been  improved  by  the  most  laudable 
diligence,  and  display  a  familiarity  with  the  whole 
subject  in  every  aspect,  which  commands  both  our 
respect  and  confidence.  As  a  corrective  of  prevalent 
and  mischievous  error,  sought  to  be  propagated  by 
novices  and  innovators,  we  could  wish  that  Dr.  La 
Roche's  book  could  be  widely  read.— iV.  Y.  Medical 
Gazette. 


LONGET  (F.  A.) 
TREATISE    ON    PHYSIOLOGY.     With  numerous  Illustrations.     Translated 

from  the  French  by  F.  G.  Smith,  M.  D.,  Professor  of  Institutes  of  Medicine  in  the  Pennsylvania 
Medical  College.     (Preparing.) 


AND    SCIENTIFIC    PUBLICATIONS.  19 

LAWRENCE  (W.),  F.  R.  S.,  &.c. 
A  TREATISE    ON   DISEASES    OF    THE    EYE.     A    new  edition,   edited, 

with  numerous  additions,  and  243  illustrations,  by  Isaac  Hays,  M.  D.,  Surgeon  to  Wills  Hospi- 
tal, &c.     In  one  very  large  and  handsome  octavo  volume,  of  950  pages,  strongly  bound  in  leather 
with  raised  bands.     {Now  Ready.) 
This  work  is  thoroughly  revised  and  brought  up  to  1854. 

This  work  is  so  universally  rect)gnized  as  the  standard  authority  on  the  subject,  that  the  pub- 
lishers in  presenting  this  new  edition  have  only  to  remark  that  in  its  preparation  the  editor  has 
carefully  revised  every  portion,  introducing  additions  and  illustrations  wherever  the  advance  of 
science  has  rendered  them  necessary  or  desirable.  In  this  manner  it  will  be  found  to  con- 
tain over  one  hundred  pages  more  than  the  last  edition,  while  the  list  of  wood-engravings 
has  been  increased  by  sixty-seven  figures,  besides  numerous  improved  illustrations  substituted 
for  such  as  were  deemed  imperfect  or  unsatisfactory.  The  various  important  contributions  to 
ophthalmological  science,  recently  made  by  Dalrymple,  Jacob,  Walton,  Wilde,  Cooper,  &c., 
both  in  the  form  of  separate  treatises  and  contributions  to  periodicals,  have  been  carefully 
examined  by  the  editor,  and,  combined  with  the  results  of  his  own  experience,  have  betn 
freely  introduced  throughout  the  volume,  rendering  it  a  complete  and  thorough  exponent  of 
the  most  advanced  state  of  the  subject.  Among  the  most  important  additions  may  be  mentioned 
a  full  account  of  the  recent  microscopical  investigations  into  the  structure  and  pathology  of  the 
eye;  the  description  of  several  affections  not  treated  of  in  the  original;  an  account  of  the 
catoptric  investigation  of  the  eye,  and  of  its  employment  as  a  means  of  diagnosis  ;  a  description 
of  recently  invented  instruments  for  illuminating  the  retina,  and  of  some  new  methods  for  examin- 
ing the  interior  structures  of  the  eye.  Very  great  improvements  will  likewise  be  found  in  the 
typographical  and  mechanical  execution  of  the  work. 

In  a  future  number  we  shall  notice  more  at  length 
this  admirable  treatise-the  safest  guide  and  most 


comprehensive  work  of  reference,  which  is  within 
the  reach  of  all  classes  of  the  profession. — Stetho- 
scope, March,  1854. 

This  standard  text-book  on  the  department  of 
which  it  treats,  has  not  been  superseded,  by  any  or 
all  of  the  numerous  publications  on  the  subject 
heretofore  issued.  Nor  with  the  multiplied  improve- 
ments of  Dr.  Hays,  the  American  editor,  is  it  at  all 


octavo  pages— has  enabled  both  author  and  editor  to 
do  justice  to  all  the  details  of  this  subject,  and  con- 
dense in  this  single  volume  the  present  state  of  our 
knowledge  of  the  whole  science  in  this  department, 
whereby  its  practical  value  cannot  be  excelled.  We 
heartily  commend  it,  especially  as  a  book  of  refe- 
rence, indispensable  in  every  medical  library.  The 
additions  of  the  American  editor  very  greatly  en- 
hance the  value  of  the  work,  exhibiting  the  learning 
and  experience  of  Dr.  Hays,  in  the  liglit  in  which  he 
ought  to  be  held,  as  a  standard  authority  on  all  sub- 


likely  that  this  great  work  will  cease  to  merit  the  1  jects  appertaining  to  this  specialty,  to  which  he  has 
confidence  and  preference  of  students  or  practi-tion-  rendered  so  many  valuable  contributions. — N.  Y. 
ers.    Its  ample  extent — nearly  one  thousand  large  |  Medical  Gazette. 

BY   THE   SAME   AUTHOR. 

A  TREATISE  ON  RUPTURES;  from  the  fifth  London  edition.    In  one  octavo 

volume,  sheep,  480  pages. 


LISTON  (ROBERT),   F.  R.  S.,  &.c. 
LECTURES  ON  THE  OPERATIONS  OF  SURGERY,  and  on  Diseases  and 

Accidents  requiring  Operations.     Edited,  with  numerous  Additions  and  Alterations,  by  T.  D. 
MiJTTER,  M.  D.     Ill  one  large  and  handsome  octavo  volume,  of  566  pages,  with  216  wood-cuts. 


LALLEMAND  (M.). 
THE    CAUSES,    SYMPTOMS,    AND    TREATMENT    OF    SPERMATOR- 
RHOEA.   Translated  and  edited  by  Henry  J.  McDougal.    In  one  volume,  octavo,  320  pages. 
Second  American  edition.     {Now  Ready.) 

LARDNER  (DIONYSIUS),  D.  C.  L.,  &;c. 
HANDBOOKS  OF  NATURAL  PHILOSOPHY  AND  ASTRONOMY. 

Kevised,  with  numerous  Additions,  by  the  American  editor.  First  Course,  containing  Mecha- 
nics, Hydrostatics,  Hydraulics,  Pneumatics,  Sound,  and  Optics.  In  one  large  royal  ]2tno. 
volume,  of  750  pages,  with  424  wood-cuts.  Second  Course,  containing  Heat,  Electricity,  Mag- 
netism, and  Galvanism,  one  volume,  large  royal  r2mo.,  of  450  pages,  with  250  illustrations. 
Third  Course  ( ?iow  ready),  containing  iVIeteorology  and  Astronomy,  in  one  large  volume,  royal 
12nio.  of  nearly  eight  hundred  pages,  with  thirty-seven  plates  and  two  hundred  wood-cuts.  The 
■whole  complete  in  three  volumes,  of  about  two  thousand  large  pages,  with  over  one  thousand 
fig-ures  on  steel  and  wood. 

The  various  sciences  treated  in  this  work  will  be  found  brought  thoroughly  up  to  tlie  latest 
period. 


The  work  furnishes  a  very  clear  and  satisfactory 
account  of  our  knowledge  in  the  important  depart- 
ment of  science  of  which  it  treats.  Although  the 
medical  schools  of  this  country  do  not  include  the 
study  of  physics  in  their  course  of  instruction,  yet 
no  student  or  practitioner  should  be  ignorant  of  its 
laws.  Besides  being  of  constant  application  in  prac- 
tice, such  knowledge  is  of  inestimable  utility  in  fa- 
cilitating the  study  of  other  branches  of  science.  To 
students,  then,  and  to  those  who,  having  already  en- 
tered upon  the  active  pursuits  of  business,  are  desir- 
ous to  sustain  and  improve  their  know^ledge  of  the 
general  truths  of  natural  philosophy,  ■we  can  recom- 
mend this  work  as  supplying  in  a  clear  and  satis 


factory  manner  the  information   they  desire. — Tke 
Virginia  Med.  and  Surg.  Journal. 

The  present  treatise  is  a  most  complete  digest  of 
all  that  has  been  developed  in  relation  to  the  great 
forces  of  nature.  Heat,  Magnetism,  and  Electricity. 
Their  la^vs  are  elucidated  in  a  manner  both  pleasing 
and  familiar,  and  at  the  same  time  perfectly  intelli- 
gible to  the  student.  The  illustrations  are  suifi- 
ciently  numerous  and  appropriate,  and  altogether 
we  can  cordially  recommend  the  work  as  well-de- 
serving the  notice  both  of  the  practising  physician 
and  the  student  of  medicine.— TAe  Med.  Examiner. 


20 


BLANCHARD    &   LEA'S   MEDICAL 


MEIGS  (CHARLES  D.),  M.  D., 

Professor  of  Obstetrics,  &c.,  in  the  Jefferson  Medical  College.  Philadelphia. 

WOMAN :  HER  DISEASES  AND  THEIR  REMEDIES.     A  Series  of  Lee- 

tiires  to  his  Class.     Third  and  Improved  edition.     In  one  large  and  beautifully  printed  octavo 
volume.     {Just  Ready.     Revised  and  enlarged  to  1854.) 

The  gratifying;  appreciation  of  his  labors,  as  evinced  by  the  exhaustion  of  two  large  impressions 
of  this  work  within  a  few  years,  has  not  been  lost  upon  the  author,  who  has  endeavored  in  every 
way  to  render  it  worthy  of  the  favor  with  which  it  has  been  received.  The  opportunity  thus 
aflbrded  for  a  second  revision  has  been  improved,  and  the  work  is  now  presented  as  in  every  way 
superior  to  its  predecessors,  additions  and  alterations  having  been  made  whenever  the  advance  of 
science  has  rendered  them  desirable.  The  typographical  execution  of  the  work  will  also  be  found 
to  have  undergone  a  similar  improvement  and  the  work  is  now  confidently  presented  as  in  every 
way  worthy  the  position  it  has  acquired  as  the  standard  American  text-bt)ok  on  the  Diseases  of 
Females. 


It  contains  a  vast  amount  of  practical  linovrledge, 
by  one  who  has  accurately  observed  and  retained 
the  experience  of  many  years,  and  who  tells  the  re- 
sult in  a  free,  familiar,  and  pleasant  manner. — Dub- 
lin Quarterly  Journal. 

Tliere  is  an  off-hand  fervor,  a  glow,  and  a  warm- 
heartedness infecting  the  effort  of  Dr.  Meigs,  which 
is  entirely  captivating,  and  which  absolutely  hur- 
ries the  reader  through  from  beginning  to  end.  Be- 
sides, the  book  teems  with  solid  instruction,  and 
it  shows  the  very  highest  evidence  of  abilit}',  viz., 
the  clearness  ^vith  which  the  information  is  pre- 
sented. We  know  of  no  better  test  of  one's  under- 
standing a  sul)ject  than  the  evidence  of  the  power 
of  lucidly  explaining  it.  The  most  elementary,  as 
well  as  the  ob.scurest  subjects,  under  the  pencil  of 
Prof.  Meigs,  are  isolated  and  made  to  stand  out  in 
such  bold  relief,  as  to  produce  distinct  impressions 
upon  the  mind  and  memory  of  the  reader.  —  The 
Charleston  Med.  Journal. 


Professor  Meigs  has  enlarged  and  amended  this 
great  work,  for  such  it  unquestionably  is,  liaving 
passed  the  ordeal  of  criticism  at  home  and  abroad, 
but  been  improved  thereby  ;  for  in  this  new  edition 
the  author  has  introduced  real  improvements,  and 
increased  the  value  and  utility  of  the  book  im- 
measurably. It  presents  so  many  novel,  bright, 
and  sparkling  thoughts;  such  an  exuberance  of  new 
ideas  on  almost  every  page,  that  we  confess  our- 
selves to  have  become  enamored  with  the  book 
and  its  author  I  and  cannot  withhold  our  congratu- 
lations from  our  Philadelphia  confreres,  that  such  a 
teacher  is  in  their  service.  We  regret  that  our 
limits  will  not  allow  of  a  more  extended  notice  of 
this  work,  but  must  content  ourselves  ■with  thus 
commending  it  as  worthy  of  diligent  perusal  by 
physicians  as  well  as  students,  who  are  seeking  to 
be  thoroughly  instructed  in  the  important  practical 
subjects  of  which  it  treats. — N.  Y.  Med.  Gazette. 


BY  THE  SAME   AUTHOR. 

OBSTETRICS :  THE  SCIENCE  AND   THE   ART.     Second  edition,  revised 

and  improved.     With  one  hundred  and  thirty-one  illustrations.     In  one  beautifully  printed  octavo 
volume,  of  seven  hundred  and  fifty-two  large  pages.     [Lately  Published.) 

The  rapid  demand  for  a  second  edition  of  this  work  is  a  sufficient  evidence  that  it  has  supplied 
a  desideratum  of  the  profession,  notwithstanding  the  numerous  treatises  on  the  same  subject  which 
have  appeared  within  the  last  few  years.  Adopting  a  system  of  his  own,  the  author  has  combined 
the  leading  principles  of  his  interesting  and  difficult  subject,  with  a  thorough  exposition  of  its  rules 
of  practice,  presenting  the  results  of  long  and  extensive  experience  and  of  familiar  acquaintance 
with  all  the  modern  writers  on  this  department  of  medicine.  As  an  American  Treatise  on  Mid- 
wifery, which  has  at  once  assumed  the  position  of  a  classic,  it  possesses  peculiar  claims  to  the  at- 
tention and  study  of  the  practitioner  and  student,  while  the  numerous  alterations  and  revisions 
which  it  has  undergone  in  the  present  edition  are  shown  by  the  great  enlargement  of  the  work, 
which  is  not  only  increased  as  to  the  size  of  the  page,  but  also  in  the  number.  Among  other  addi- 
tions may  be  mentioned 

A  NEW  AND  IMPORTANT  CHAPTER  ON  "CHILDBED  FEVER." 

BY   THE   SAME   AUTHOR.      (NoW  Ready.) 

A  TREATISE  ON  ACUTE  AND  CHRONIC  DISEASES  OF  THE  NECK 

OF  THE  UTERUS.     With  numerous  plates,  drawn  and  colored  from  nature  in  the  highest 
style  of  art.    In  one  handsome  octavo  volume,  extra  cloth. 

The  object  of  the  author  in  this  work  has  been  to  present  in  a  small  compass  the  practical  results 
of  his  long  experience  in  this  important  and  distressing  class  of  diseases.  The  great  changes  intro- 
duced into  practice,  and  the  accessions  to  our  knowledge  on  the  subject,  within  the  last  few  years, 
resulting  from  the  use  of  the  metroscope,  brings  within  the  ordinary  practice  of  every  physician 
numerous  cases  which  were  formerly  regarded  as  incurable,  and  renders  of  great  value  a  work  like 
the  present  combining  practical  directions  for  diagnosis  and  treatment  with  an  ample  series  of  illus- 
trations, copied  accurately  from  colored  drawings  made  by  the  author,  after  nature.  No  such  accu- 
rate delineations  of  the  pathology  of  the  neck  of  the  uterus  have  heretofore  been  given,  requiring, 
as  they  do  the  rare  combination  of  physician  and  artist,  and  their  paramount  importance  to  the 
physician  in  whose  practice  such  cases  are  frequent,  is  too  evident  to  be  dwelt  upon,  while  in 
artistic  execution  they  are  far  in  advance  of  anything  of  the  kind  as  yet  produced  in  this  country. 


BY   THE   SAME  AUTHOR. 

OBSERVATIONS   ON    CERTAIN    OF    THE    DISEASES    OF    YOUNG 

CHILDREN.    la  one  handsome  octavo  volume,  of  214  pages. 

BY  THE  SAME  AUTHOR.     (Preparing.) 

ON    THE    NATURE,    SIGNS,    AND    TREATMENT    OF    PUERPERAL 

FEVER.    In  one  handsome  octavo  volume. 


AND    SCIENTIFIC    P  LTBLIC  ATIONS. 


21 


MILLER  (JAMES),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Edinburgh.  &c. 

PRINCIPLES  OF  SURGERY.     Third  American,  from  the  second  and  revi.sed 

Edinburgh  edition.  Revised,  with  Additions,  byF.  W.  Sargent,  M.  D.,  author  of  "Minor  Sur- 
gery," &c.  In  one  large  and  very  beautiful  volume,  of  seven  hundred  and  fifty-two  pa"-es,  with 
two  hundred  and  forty  exquisite  illustrations  on  wood.  ° 

The  publishers  have  endeavored  to  render  the  present  edition  of  this  work,  in  every  point  of  me- 
chanical execution,  worthy  of  its  very  high  reputation,  and  they  confidently  present  it  to  the  pro- 
fession as  one  of  the  handsomest  volumes  as  yet  issued  in  this  country. 

This  edition  is  far  superior,  both  in  the  abundance  !  guagje.  This  opinion,  deliberately  formed  after  a 
and  quality  of  its  material,  to  any  of  the  preceding,  j  careful  study  of  the  first  edition,  we  have  had  no 
"We  hope  it  U'ill  be  extensively  read,  and  the  sound  |  cause  to  change  on   examining   the   second.     This 

edition  has  undergone  thorough  revision  l)y  the  au- 
thor; many  expressions  have  been  modified,  and  a 
mass  of  new  matter  introduced.  The  book  is  got  up 
in  the  finest  style,  and  is  an  evidence  of  the  prnsress 
of  typography  in  our  country. — Charleston  Medical 
Journal  and  Review. 


We  recommend  it  to  both  student  and  practitioner, 
feeling  assured  that  as  it  now  comes  to  us,  it  pre- 
sents the  most  satisfactory  exposition  of  the  modern 
doctrines  of  the  principles  of  surgery  to  be  found  in 
any  volume  in  any  language. — N.  Y.  Journal  of 
Medicine. 


principles  wliich  are  herein  taught  treasured  up  for 
future  application.  The  work  takes  rank  with 
Watson's  Practice  of  Physic;  it  certainly  does  not 
fall  behind  that  great  work  in  soundness  of  princi- 
ple or  depth  of  reasoning  and  research.  No  physi- 
cian who  values  his  reputation,  or  seeks  the  interests 
of  his  clients,  can  acquit  himself  before  his  God  and 
the  ■world  without  making  himself  familiar  with  the 
sound  and  philosophical  views  developed  in  the  fore- 
going book. — New  Orleans  Medical  and  Surgical 
Journal. 

AVithout  doubt  the  ablest  exposition  of  the  prin- 
ciples of  that  branch  of  the  healing  art  in  any  lan- 

BY   THE   SAME   AUTHOR.      (NoW  Ready.) 

THE  PRACTICE  OF   SURGERY.     Third  American  from  the  second  Elin- 

burgh  edition.     Edited,  with  Additions,  by  F.  W.  Sargent,  M.  D  ,  one  of  the  Surgeons  to  Will's 

Hcspital,  i?cc.     Illustrated  by  three  hundred  and  nineteen  engravings  on  wood.    In  one  large 

octavo  volume,  of  over  seven  hundred  pages. 

This  new^  edition  will  be  found  greatly  improved  and  enlarged,  as  ^vell  by  the  addition  of  much 
new  matter  as  by  the  introduction  of  a  large  and  complete  series  of  handsome  illustraiions.  An 
equal  improvement  exists  in  the  mechanical  execution  of  the  work,  rendering  it  in  every  respect 
a  companion  volume  to  the  "  Principles." 

No  encomium  of  ours  could  add  to  the  popularity  I  By  the  almost  unanimous  voice  of  the  profession, 
of  Miller's  Surgery.  Its  reputation  in  this  country  !  his  works,  both  on  the  principles  and  practice  of 
is  unsurpassed  by  that  of  any  other  work,  and,  when  ■  surgery  have  been  assigned  the  highest  rank.     If  we 


taken  in  ctmnection  with  the  author's  Principles  of 
Surgery,  constitutes  a  whole,  without  reference  to 
which  no  conscientious  surgeon  would  be  willing 
to  practice  his  art  The  additions,  by  Dr.  Sargent, 
have  materially  enhanced  the  value  of  the  work. — 
Southern  Medical  and  Surgical  Journal. 

It  is  seldom  that  two  volumes  have  ever  made  so 
profound  an  impression  in  so  short  a  time  as  the 
"  Principles"  and  the  "  Practice"  of  Surgery  by 
Mr.  Miller — or  so  richly  merited  the  reputation  they 
have  acquired.  The  author  is  an  eminently  sensi- 
ble, practical,  and  \vell-informed  man,  who  knows 
exactly  what  he  is  talking  about  and  exactly  how  to 
talk  it. —  Kentuclcy  Medical  Recorder. 

The  two  volumes  together  form  a  complete  expose 
of  the  present  state  of  Surgery,  and  they  ought  to  be 
on  tlie  shelves  of  every  surgeoa. — N.  J.  Med.  Re- 
porter. 


were  limited  to  but  one  work  on  surgery,  that  one 
should  be  Miller's,  as  we  regard  it  superior  to  all 
others. — St.  Louis  Med.  and  Surg.  Journal. 

The  author  distinguished  alike  as  a  practitioner 
and  writer,  has  in  this  and  his  "  Principles,''  pre- 
sented to  the  profession  one  of  the  most  completeand 
reliable  systems  of  Surgery  extant.  His  style  of 
writing  is  original,  impressive,  and  engaging,  ener- 
getic, concise,  and  lucid.  Few  have  the  faculty  of 
condensing  so  much  in  small  space,  and  at  the  same 
time  so  persistently  holding  the  attention;  indeed, 
he  appears  to  make  the  very  process  of  condensation 
a  means  of  eliminating  attractions.  Whether  as  a 
text-book  for  students  or  a  book  of  reference  for 
practitioners,  it  cannot  be  too  strongly  recommend- 
ed.— Southern  Journal  of  the  Medical  and  Physical 
Sciences. 


MALGAIGNE  (J.  F.). 
OPERATIVE  SURGERY,  based  on  Normal  and  Pathological  Anatomy.     Trans- 
lated from  the  French,  by  Frederick  Brittan,  A.  B.,  M.  D.    With  numerous  illustrations  oa 
wood.     In  one  handsome  octavo  volume,  of  nearly  six  hundred  pages. 


AVe  have  long  been  accustomed  to  refer  to  it  as  one 
of  the  most  valuable  text-books  in  our  library. — 
Buffalo  Med.  and  Surg.  Journal. 

Certainly  one  of  the  best  books  published  on  ope- 
rative surgery. — Edinburgh  Medical  Journal. 


To  express  in  a  few  words  our  opinion  of  Mal- 
gaigne's  work,  we  unhesitatingly  pronounce  it  the 
very  best  guide  in  surgical  operations  that  has  come 
before  the  profession  in  any  language. — Charleston 
Med.  and  Surg.  Journal. 


MOHR  (FRANCIS),  PH.  D.,  AND  REDWOOD  (TH  EOPH  I  LUS). 
PRACTICAL    PHARMACY.     Comprising  the  Arrangements,  Apparatus,  and 

Manipulations  of  the  Pharmaceutical  Shop  and  Laboratory.    Edited,  with  extensive  Additions, 
by  Prof.  William  Procter,  of  the  Philadelphia  College  of  Pharmacy.    In  one  handsomely 
printed  octavo  volume,  of  570  pages,  with  over  500  engravings  on  wood. 
It  is  a  book,  however,  Avhich  will  be  in  the  hands 
of  almost  every  one  who  is  much  interested  in  phar- 
maceutical operations,  as  we  know  of  no  other  pub- 
lication so  well  calculated  to  fill  a  void  long  felt. — 
Medical  Examiner. 


The  book  is  strictly  practical,  and  describes  only 
manipulations  or  methods  of  performing  the  nume- 
rous processes  the  pharmaceutist  has  to  go  through, 
in  the  preparation  and  manufacture  of  medicines, 
together  with  all  the  apparatus  and  fixtures  neces- 


sary thereto.  On  these  matters,  this  work  is  very 
full  and  complete,  and  details,  in  a  style  uncom- 
monly clear  and  lucid,  not  only  the  more  compli- 
cated and  difficult  processes,  but  those  not  less  im- 
portant ones,  the  most  simple  and  common. — Buffalo 
Medical  Journal. 


The  country  practitioner  who  is  obliged  to  dis- 
pense his  own  medicines,  \vill  find  it  a  most  valuable 
assistant. — Monthly  Journal  and  Retrospect. 


22 


BLANCHARD    &    LEA'S    MEDICAL 


MACLISE   (JOSEPH),    SURGEON. 
SURGICAL  ANATOMY.     Forming  one  volume,   very  large  imperial  quarto. 

With  sixty-eight  large  and  splendid  Plates,  drawn  in  the  best  style  and  beautifully  colored.  Con- 
taining one  hundred  and  ninety  Figures,  many  of  them  the  size  of  life.  Together  with  copious 
and  explanatory  letter-press.  Strongly  and  handsomely  bound  in  extra  cloth,  being  one  of  the 
cheapest  and  best  executed  Surgical  works  as  yet  issued  in  this  country. 

Copies  can  be  sent  by  mail,  in  five  parts,  done  up  in  stout  covers. 

This  great  work  being  now  concluded,  the  publishers  confidently  present  it  to  the  attention  of  the 
profession  as  worthy  in  every  respect  of  their  approbation  and  patronage.  No  complete  work  of 
the  kind  has  yet  been  published  in  the  English  language,  and  it  therefore  will  supply  a  want  long 
felt  in  this  country  of  an  accurate  and  comprehensive  Atlas  of  Surgical  Anatomy  to  which  the 
student  and  practitioner  can  at  all  times  refer,  to  ascertain  the  exact  relative  position  of  the  various 
portions  of  the  human  frame  towards  each  other  and  to  the  surface,  as  well  as  their  abnormal  de- 
viations. The  importance  of  such  a  work  to  the  student  in  the  absence  of  anatomical  material,  and 
to  the  practitioner  when  about  attempting  an  operation,  is  evident,  while  the  price  of  the  book,  not- 
withstanding the  large  size,  beauty,  and  finish  of  the  very  numerous  illustrations,  is  so  low  as  to 
place  it  within  the  reach  of  every  member  of  the  profession.  The  publishers  therefore  confidently 
anticipate  a  very  extended  circulation  for  this  magnificent  work. 


One  of  the  greatest  artistic  triumphs  of  the  age 
in  Surgical  Anatomy. — British  American  Medical 
Journal.  ' 

Too  much  cannot  be  said  in  its  praise  ;  indeed, 
we  have  not  language  to  do  it  justice. — O/iio  Medi- 
cal and  Surgical  Journal. 

The  most  admirable  surgical  atlas  we  have  seen. 
To  the  practitioner  deprived  of  demonstrative  dis- 
sections upon  the  human  subject,  it  is  an  invaluable 
companion.— iV.  J.  Medical  Reporter. 

The  most  accurately  engraved  and  beautifully 
colored  plates  we  have  ever  seen  in  an  American 
book — one  of  the  best  and  cheapest  surgical  works 
ever  published. — Buffalo  Medical  Journal. 

It  is  very  rare  that  so  elegantly  printed,  bo  well 
illustrated,  and  so  useful  a  work,  is  offered  at  so 
moderate  a  price. — Charleston  Medical  Journal. 

Its  plates  can  boast  a  superiority  which  places 
them  almost  beyond  the  reach  of  competition.— Merfi- 
cal  Examiner . 

Every  practitioner,  we  think,  should  have  a  work 
of  this  kind  within  reach. — Southern  Medical  and 
Surgical  Journal. 

No  such  lithographic  illustrations  of  surgical  re- 
gions have  hitherto,  we  think,  been  giyta.— Boston 
Medical  and  Surgical  Journal. 

As  a  surgical  anatomist,  Mr.  Maclise  has  proba- 
bly no  superior.— Brt^isA  and  Foreign  Medico-Chi- 
rurgical  Revieiv. 

Of  great  value  to  the  student  engaged  in  dissect- 
ing, and  to  the  surgeon  at  a  distance  from  the  means 


of  keeping  up  his  anatomical  knowledge. — Medical 
Times. 

The  mechanical  execution  cannot  be  excelled. — 
Transylvania  Medical  Journal. 

A  work  which  has  no  parallel  in  point  of  accu- 
racy and  cheapness  in  the  English  language. — N.  Y. 
Journal  of  Medicine. 

To  all  engaged  in  the  study  or  practice  of  their 
profession,  such  a  work  is  almost  indispensable. — 
Dublin  Quarterly  Medical  Journal, 

No  practitioner  whose  means  will  admit  should 
fail  to  possess  it. — Ranking^s  Abstract. 

Country  practitioners  will  find  these  plates  of  im- 
mense value. — N.  Y.  Medical  Gazette. 

We  are  extremely  gratified  to  announce  to  the 
profession  the  completion  of  this  truly  magnificent 
work,  which,  as  a  whole,  certainly  stands  unri- 
valled, both  for  accuracy  of  drawing,  beauty  of 
coloring,  and  all  the  requisite  explanations  of  the 
subject  in  hand.: — The  New  Orleans  Medical  and 
Surgical  Journal. 

This  is  by  far  the  ablest  work  on  Surgical  Ana- 
tomy that  has  come  under  our  observation.  We 
know  of  no  other  work  that  would  justify  a  stu- 
dent, in  any  degree,  for  neglect  of  actual  dissec- 
tion. In  those  sudden  emergencies  that  so  often 
arise,  and  which  require  the  instantaneous  command 
of  minute  anatomical  knowledge,  a  work  of  this  kind 
keeps  the  details  of  the  dissecting-room  perpetually 
fresh  in  the  memory. — The  Western  Journal  of  Medi- 
cine and  Surgery. 


Jl^^  The  very  low  price  at  which  this  work  is  furnished,  and  the  beauty  of  its  execution, 
require  an  extended  sale  to  compensate  the  publishers  for  the  heavy  expenses  incurred. 


MULLER  (PROFESSOR  J.),   M .  D. 
PEINCIPLES  OF  PHYSICS  AND  METEOROLOGY.    Edited,  with  Addi- 

tions,  by  R.  Eglesfeld  Griffith,  M.  D.    In  one  large  and  handsome  octavo  volume,  extra 
cloth,  with  550  wood-cuts,  and  two  colored  plates. 

The  Physics  of  Mailer  is  a  work  superb,  complete.  I  tion  to  the  scientific  records  of  this  country  may  be 
unique:  thegreatest  want  known  to  English  Science  j  duly  estimated  by  the  fact  that  the  cost  of  the  origi- 
could  not  have  been  better  supplied.  The  work  is  I  nal  drawings  and  engravings  alone  has  exceeded  the 
of  surpassing  interest.    The  value  of  this  contribu-  |  sum  of  £2,000.— Lancet. 


MAYNE  (JOHN),  M.  D,,  M.  R.  C.  S., 
A  DISPENSATORY  AND  THERAPEUTICAL  REMEMBRANCER.   Com- 

prising  the  entire  lists  of  Materia  Medica,  with  every  Practical  Formula  contained  in  the  three 
British  Pharmacopoeias.  With  relative  Tables  subjoined,  illustrating,  by  upwards  of  six  hundred 
and  sixty  examples,  the  Extemporaneous  Forms  and  Combinations  suitable  for  the  different 
Medicines.  Edited,  with  the  addition  of  the  Formulae  of  the  United  States  Pharmacopceia,  by 
R.  Eglesfeld  Griffith,  M.  D.    In  one  12mo.  volume,  extra  cloth,  of  over  300  large  pages. 


MATTEUCCI  (CARLO). 
LECTURES  ON  THE  PHYSICAL  PHENOMENA  OF  LIVING  BEINGS. 

Edited  by  J.  Pereira,  M.  D.    In  one  neat  royal  12mo.  volume,  extra  cloth,  with  cuts,  388  pages- 


AND   SCIENTIFIC    PUBLICATIONS.  23 

NEILL  (JOHN),   M.  D., 

Surgeon  to  the  Pennsylvania  Hospital,  &c.;  and 
FRANCIS  GURNEY  SMITH,   M.D., 

Professor  of  Institutes  of  Medicine  in  the  Pennsylvania  Medical  College. 

AN  ANALYTICAL  COMPENDIUM  OF  THE  VARIOUS  BRANCHES 

OF  MEDICAL  SCIENCE  ;  for  the  Use  and  Examination  of  Students.  Second  edition,  revised 
and  improved.  In  one  very  large  and  handsomely  printed  royal  12mo.  volume,  of  over  one 
thousand  pages,  "with  three  hundred  and  fifty  illustrations  on  wood.  Strongly  bound  in  leather, 
with  raised  bands. 

The  speedy  sale  of  a  large  impression  of  this  work  has  afforded  to  the  authors  gratifying  evidence 
of  the  correctness  of  the  views  which  actuated  them  in  its  preparation.  In  meeting  the  demand 
for  a  second  edition,  they  have  therefore  been  desirous  to  render  it  more  worthy  of  the  favor  with 
which  it  has  been  received.  To  accomplish  this,  they  have  spared  neither  time  nor  labor  in  embo- 
dying in  it  such  discoveries  and  improvements  as  have  been  made  since  its  first  appearance,  and 
such  alterations  as  have  been  suggested  by  its  practical  use  in  the  class  and  examination-room. 
Considerable  modifications  have  thus  been  introduced  throughout  all  the  departments  treated  of  ui 
the  volume,  but  more  especially  in  the  portion  devoted  to  the  "Practice  of  Medicine,"  which  has 
been  entirely  rearranged  and  rewritten.  The  authors  therefore  again  submit  their  work  to  the 
profession,  with  the  hope  that  their  efibrts  may  tend,  however  humbly,  to  advance  the  great  cause 
of  medical  education. 

Notwithstanding  the  enlarged  size  and  improved  execution  of  this  work,  the  price  has  not  been 
increased,  and  it  is  confidently  presented  as  one  of  the  cheapest  volumes  now  before  the  profession. 

Having  made  free  use  of  this  volume  in  our  ex- 
aminations of  pupils,  we  can  speak  from  experi- 
ence in  recommending  it  as  an  admirable  compend 


In  the  rapid  course  of  lectures,  where  work  for 
the  students  is  heavy,  and  review  necessary  for  an 
examination,  a  compend  is  not  only  valuable,  but 
it  is  almost  a  sine  qua  non.  The  one  before  us  is, 
in  most  of  the  divisions,  the  most  unexceptionable 
of  all  books  of  the  kind  that  we  know  of.  The 
newest  and  soundest  doctrines  and  the  latest  im- 
provements and  discoveries  are  explicitly,  though 
concisely,  laid  before  the  student.  Of  course  it  is 
useless  for  us  to  recommend  it  to  all  last  course 
students,  but  there  is  a  class  to  whom  we  very 
sincerely  commend  this  cheap  book  as  worth  its 
Weight  in  silver  —  that  class  is  the  graduates  in 
medicine  of  more  than  ten  years'  standing,  who 
have  not  studied  medicine  since.  They  \vill  perhaps 
find  out  from  it  that  the  science  is  not  exactly  now 
what  it  was  when  they  left  it  off. — The  Stethoscope 


for  students,  and  as  especially  useful  to  preceptors 
who  examine  their  pupils.  It  will  save  the  teacher 
much  labor  by  enabling  him  readily  to  recall  all  of 
the  points  upon  which  his  pupils  should  be  ex- 
amined. A  work  of  this  sort  should  be  in  the  hands 
of  every  one  who  takes  pupils  into  his  office  with  a 
viewof  examining  them;  and  this  is  unquestionably 
the  best  of  its  class.  Let  every  practitioner  who  has 
pupils  provide  himself  with  it,  and  he  will  find  the 
labor  of  refreshing  his  knowledge  so  much  facilitated 
that  he  will  be  able  to  do  justice  to  his  pupils  at  very 
little  cost  of  time  or  trouble  to  himself. — Transyl' 
vania  Med.  Journal. 


NELIGAN  (J.    MOORE),  M.  D.,  M.  R.  I.  A.,  &.C. 
A   PRACTICAL  TREATISE    ON   DISEASES   OF   THE    SKIN.     In  one 

neat  royal  12mo.  volume,  of  334  pages. 

OWEN  (PROF.    R). 
ON  THE  DIFFERENT  FORMS  OF  THE  SKELETON.     One  vol.  royal 

12mo.,  with  numerous  illustrations.     (^Preparing.) 

POPULAR    PHYSIOLOGY. 
THE   PHYSIOLOGY  OF   ANIMAL   AND   VEGETABLE   LIFE.     In  one 

neat  royal  12mo.  volume,  of  about  200  pages,  with  100  wood-cuts.     (Just  Ready.) 
The  latest  information  on  physiological  subjects  will  be  found  in  this  work,  popularly  and  clearly 
explained,  rendering  it  suitable  for  schools  and  school  libraries,  as  well  as  for  private  readers. 

PHILLIPS  (BENJAMIN),   F.  R.  S.,  &c. 

SCROFULA ;  its  Nature,  its  Prevalence,  its  Causes,  and  the  Principles  of  its 
Treatment.    In  one  volume,  octavo,  with  a  plate. 

PANCOAST  (J.),  M.  D., 

Professor  of  Anatomy  in  the  Jefferson  Medical  College,  Philadelphia,  &c. 

OPERATIVE  SURGERY;  or,  A  Description  and  Demonstration  of  the  various 

Processes  of  the  Art;  including  all  the  New  Operations,  and  exhibiting  the  State  of  Surgical 

Science  in  its  present  advanced  condition.     Complete  in  one  roval  4to.  volume,  of  380  pages  of 

letter-press  description  and  eighty  large  4to.  plates,  comprising  486  illustrations.     Second  edition, 

improved. 

Blanchard  &  Lea  having  become  the  publishers  of  this  important  book,  liave  much  pleasure  in 

oflering  it  to  the  profession. 

This  excellent  work  is  constructed  on  the  model  I  cerned,  we  are  proud  as  an  American  to  say  that, 

of  the  French  Surgical  Works  by  Velpeau  and  Mai-  I  of  its  kind  it  has  no  supekiok.— iV.  Y.  Journal  of 

gaigne;  and,  so  far  as  the  English  language  is  con-  |  Medicine. 

PARKER   (LANGSTON)., 

Surgeon  to  the  Queen's  Hospital,  Birmingham. 

THE  MODERN  TREATMENT  OP  SYPHILITIC  DISEASES,  BOTH  PRI- 
MARY AND  SECONDARY;  comprisingtheTreatment  of  Constitutional  and  Confirmed  Syphi- 
lis, by  a  safe  and  successful  method.  With  numerous  Cases,  Formulae,  and  Clinical  Observa- 
tions. From  the  Third  and  entirely  rewritten  London  edition.  In  one  neat  octavo  volume. 
{Nearly  Ready.) 


24 


BLANCHARD   &    LEA'S   MEDICAL 


{Now  Complete.) 
PEREIRA  (JONATHAN),  M.  D,,  F.  R.  S.,  AND  L.  S. 
ELEMENTS    OP    MATERIA    MEDICA    AND    THERAPEUTICS. 


THE 

Third  American  edition,  enlarged  and  improved  by  the  author;  including  Notices  of  most  of  the 
Medicinal  Substances  in  use  in  the  civilized  wrorld.  and  forming  an  Encyclopfedia  of  Materia 
Medica.  Edited,  with  Additions,  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and 
Pharmacy  in  the  University  of  Pennsylvania.  In  two  very  large  octavo  volumes  of  2100  pages, 
on  small  type,  with  over  four  hundred  and  fifty  illustrations. 

Volume  I. — Lately  issued,  containing  the  Inorganic  Materia  Medica,  over  800  pages,  w^ith  145 

illustrations. 
Volume  II. — Now  ready,  embraces  the  Organic  Materia  Medica,  and  forms  a  very  large  octavo 

volume  of  1250  pages,  with  two  plates  and  three  hundred  handsome  wood-cuts. 

The  present  edition  of  this  valuable  and  standard  work  will  enhance  in  every  respect  its  well- 
deserved  reputation.  The  care  bestowed  upon  its  revision  by  the  author  may  be  estimated  by  the 
fact  that  its  size  has  been  increased  by  about  five  hundred  pages.  These  additions  have  extended 
to  evfery  portion  of  the  work,  and  embrace  not  only  the  materials  afforded  by  the  recent  editions  of 
the  pharmacopcfiias,  but  also  all  the  important  information  accessible  to  the  care  and  industry  of 
the  author  in  treatises,  essays,  memoirs,  monographs,  and  from  correspondents  in  various  parts  of 
the  globe.  In  this  manner  the  work  comprises  the  most  recent  and  reliable  information  respecting 
all  the  articles  of  the  Materia  Medica,  their  natural  and  commercial  history,  chemical  and  thera- 
peutical properties,  preparation,  uses,  doses,  and  modes  of  administration,  brought  up  tg  the  present 
time,  with  a  completeness  not  to  be  met  with  elsewhere.  A  considerable  portion  of  the  work 
which  preceded  the  remainder  in  London,  has  also  enjoyed  the  advantage  of  a  further  revision  by 
the  author  expressly  for  this  country,  and  in  addition  to  this  the  editor,  Professor  Carson,  has  made 
whatever  additions  appeared  desirable  to  adapt  it  thoroughly  to  the  U.  S.  Pharmacoposia,  and  to 
the  wants  of  the  American  profession.  An  equal  improvement  will  likewise  be  observable  in  every 
department  of  its  mechanical  execution.  It  is  printed  from  new  type,  on  good  white  paper,  with  a 
greatly  extended  and  improved  series  of  illustrations. 

Gentlemen  who  have  the  first  volume  are  recommended  to  complete  their  copies  without  delay. 
The  first  volume  will  no  longer  be  sold  separate. 


AVhen  we  remember  that  Philology,  Natural  His- 
toric Botany,  Chemistry,  Physics,  and  the  Micro- 
scope, are  all  brought  forward  to  elucidate  the  sub- 
ject, one  cannot  fail  to  see  that  the  reader  has  here 
a  work  worthy  of  the  name  of  an  encyclopedia  of 
Materia  Medica.  Our  own  opinion  of  its  merits  is 
that  of  its  editors,  and  also  that  of  the  whole  profes- 
sion, both  of  this  and  foreign  countries— namely, 
"  that  in  copiousness  of  details,  in  extent,  variety, 
and  accuracy  of  information,  and  in  lucid  explana- 
tion of  difficult  and  recondite  subjects,  it  surpasses 
all  other  worlcs  on  Materia  Medica  hitherto  pub- 
lished," We  cannot  close  this  notice  without  allud- 
ing to  the  special  additions  of  the  American  editor, 
which  pertain  to  the  prominent  vegetable  produc- 
tions of  this  country,  and  to  the  directions  of  the 
United  States  PharmacopoBia,  in  connection  with  all 
the  articles  contained  in  the  volume  which  are  re- 
ferred to  by  it.  The  illustrations  have  been  increased, 
and  this  edition  by  Dr.  Carson  cannot  well  be  re- 
garded in  any  other  light  than  that  of  a  treasure 
^Vhich  should  be  found  in  the  library  of  every  physi- 
cian.— New  York  Journal  of  Medical  and  Collateral 
Science,  March,  1854. 

The  third  edition  of  his  "Elements  of  Materia 


Medica,  although  completed  under  the  supervision  of 
others,  is  by  far  the  most  elaborate  treatise  in  the 
English  language,  and  will,  while  medical  literature 
is  cherished,  continue  a  monument  alike  honorable 
to  his  genius,  as  to  his  learning  and  industry. — 
American  Journal  of  Pharmacy,  March,  1854. 

The  work,  in  its  present  shape,  and  so  far  as  can 
be  judged  from  the  portion  before  the  public,  forms 
the  most  comprehensive  and  complete  treatise  on 
materia  medica  extant  in  the  English  language. — 
Dr.  Pereira  has  been  nt  great  pains  to  introduce 
into  his  work,  not  only  all  the  information  on  the 
natural,  chemical,  and  commercial  history  of  medi- 
cines, which  might  be  serviceable  to  the  physician 
and  surgeon,  but  whatever  might  enable  his  read- 
ers to  understand  thoroughly  the  mode  of  prepar- 
ing and  manufacturing  various  articles  employed 
either  for  preparing  medicines,  or  for  certain  pur- 
poses in  the  arts  connected  with  materia  medica 
and  the  practice  of  medicine.  The  accounts  of  the 
physiological  and  therapeutic  effects  of  remedies  are 
given  with  great  clearness  and  accuracy,  and  in  a 
manner  calculated  to  interest  as  well  as  instruct 
the  reader. — The  Edinburgh  Medical  and  Surgical 
Journal, 


PEASELEE  (E.   R.),   M.  D. 

Professor  of  Anatomy  and  Physiology  in  Dartmouth  College,  &c. 

HUMAN  HISTOLOG-Y,  in  its  applications  to  Physiology  and  G-eneral  Pathology, 

designed  as  a  Text-Book  for  Medical  Students.    With  numerous  illustrations.     In  one  handsome 
royal  12mo.  volume.     {Preparing.) 

The  subject  of  this  work  is  one,  the  growing  importance  of  which,  as  the  basis  of  Anatomy  and 
Physiology,  demands  for  it  a  separate  volume.  The  book  will  therefore  supply  an  acknowledged 
deficiency  in  medical  text-books,  while  the  name  of  the  author,  and  his  experience  as  a  teacher  for 
the  last  thirteen  years,  is  a  guarantee  that  it  will  be  thoroughly  adapted  to  the  use  of  the  student. 


PIRRIE  (WILLIAM),  F.  R.  S.  E., 

Professor  of  Surgery  in  the  University  of  Aberdeen. 

THE    PRINCIPLES  AND  PRACTICE  OP  SURGERY.    Edited  by  John 

Neill,  M.  D.,  Demonstrator  of  Anatomy  in  the  University  of  Pennsylvania,  Surgeon  to  the 
Pennsylvania  Hospital,  &c.  la  one  very  handsome  octavo  volume,  of  780  pages,  with  316  illus- 
trations.    {Just  Issued.) 


We  know  of  no  other  surgical  work  of  a  reason- 
able size,  wherein  there  is  so  much  theory  and  prac- 
tice, or  where  subjects  are  more  soundly  or  clearly 
taught. — The  Stethoscope. 

There  is  scarcely  a  disease  of  the  bone  or  soft 
parts,  fracture,  or  dislocation,  that  is  not  illustrated 
by  accurate  wood-engravings.  Then,  again,  every 
instrument  employed  by  the  surgeon  is  thus  repre- 
sented. These  engravings  are  not  only  correct,  but 
really  beautiful,  showing  the  astonishing  degree  of 
perfection  to  which  the  art  of  wood- engraving  has 


arrived.  Prof.  Pirrie,  in  the  work  before  us,  has 
elaborately  discussed  the  principles  of  surgery,  and 
a  safe  and  effectual  practice  predicated  upon  them. 
Perhaps  no  work  upon  this  subject  heretofore  issued 
is  so  full  upon  the  science  of  the  art  of  surgery. — 
Nashville  Journal  of  Medicine  and  Surgery. 

One  of  the  best  treatises  on  surgery  in  the  English 
language. — Canada  Med.  Journal. 

Our  impression  is,  that,  as  a  manual  for  students, 
Pirrie's  is  the  best  work  extant. — Western  Med.  and 
Surg.  Journal. 


AND    SCIENTIFIC    PUBLICATIONS.  25 

RAMSBOTHAM  (FRANCIS   H .),   M.D. 
THE  PRINCIPLES  AND  PRACTICE  OF  OBSTETRIC  MEDICINE  AND 

SURGERY,  in  reference  to  the  Process  of  Parturition.     Sixth  American,  from  the  last  London 

edition.     Illustrated  with  one  hundred  and  forty-eight  Figures,  on  fifty-five  Lithographic  Plates. 

In  one  large  and  handsomely  prnited  volume,  imperial  octavo,  with  520  pages. 

In  this  edition,  the  plates  have  all  been  redrawn,  and  the  text  carefully  read  and  corrected.     It 
is  therefore  presented  as  in  every  way  worthy  the  favor  with  which  it  has  so  long  been  received. 
From  Prof.  Hodge,  of  the  University  of  Pa. 

To  the  American  public,  it  is  most  valuable,  from  its  intrinsic  undoubted  excellence,  and  as  bein" 
the  best  authorized  exponent  of  British  Midwifery.  Its  circulation  will,  I  trust,  be  extensive  throuo-houl 
our  country.  ° 

When  the  whole  profession  is  thus  unanimous 
in  phicing  such  a  work  in  the  very  first  rank  as 
regards  the  extent  and  correctness  of  all  the  details 
of  the  theory  and  practice  of  so  important  a  branch 
of  learning,  our  commendation  or  condemnation 
would  be  of  little  consequence;  but  regarding  it 
as  the  most  useful  of  all  works  of  the"  kind,  we 
think  it  but  an  act  of  justice  to  urge  its  claims 
upon  the  profession. — N.  O.  Med.  Journal. 


yVe  recommend  the  student  who  desires  to  mas- 
ter this  difficult  subject  with  the  least  possible 
trouble,  to  possess  himself  at  once  of  a  copy  of  this 
work. — Ajiierican  .Journal  of  the  Med.  Sciences. 

It  stands  at  the  head  of  the  long  list  of  excellent 
obstetric  works  published  in  the  last  few  years  in 
Great  Britain,  Ireland,  and  the  Continent  of  Eu- 
rope. We  consider  this  book  indispensable  to  the 
library  of  every  physician  engaged  in  the  practice 
of  mictwifery. —  Southern  Med.  and  Surg.  Journal. 


RICORD  (P.),   M.  D., 
Surgeon  to  the  Hopital  du  Midi,  Paris,  &c. 

ILLUSTRATIONS  OF  SYPHILITIC  DISEASE.   Translated  from  the  French, 

by  Thomas  F.  Betton,  M.  D.  With  the  addition  of  a  History  of  Syphilis,  and  a  complete  Bib- 
liography and  Formulary  of  Remedies,  collated  and  arranged,  by  Paul  B.  Goddard,  M.D.  With 
fifty  large  quarto  plates,  comprising  one  hundred  and  seventeen  beautifully  colored  illustrations. 
Ill  one  large  and  handsome  quarto  volume. 

Blanchard  &  Lea  having  purchased  the  remainder  of  this  valuable  work,  which  was  originally 
soid  as  a  subscription  book,  are  now  prepared  to  offer  it  to  the  profession.  It  is  universally  known 
as  one  of  the  handsomest  volumes  as  yet  presented  in  this  country,  and  as  containing  the  only  ex- 
tended and  thorough  series  of  illustrations  on  the  subject. 

BY  THE  SAME  AUTHOE.     (JVow  Ready.) 

A  TREATISE  ON  THE  VENEREAL  DISEASE.     By  John  Hunter,  P.  R.  S. 

With  copious  Additions,  by  Ph.  Ricord,  M.  D.  Edited,  with  Notes,  by  Freeman  J.  Bumstead, 
M.  D.    In  one  handsome  octavo  volume,  with  plates. 

From  the  Translator's  Preface. 

"  M.  Ricord's  annotations  to  Hunter''s  Treatise  on  the  Venereal  Disease  were  first  published  at 
Paris,  in  1S40,  in  connection  with  Dr.  G.  Richelot's  translation  of  the  work,  including  the  contri- 
butions of  Sir  Everard  Home  and  Mr.  Babington.  In  a  second  edition,  which  has  recently  ap- 
peared, M.  Ricord  has  thoroughly  revised  his  part  of  the  work,  bringing  it  up  to  the  knowledge  of 
the  present  day,  and  so  materially  increasing  it  that  it  now  constitutes  full  one-tliird  of  the  volume. 

"  This  publication  has  been  received  with  great  favor  by  the  French,  both  because  it  has  placed 
within  their  reach  an  important  work  of  Hunter,  and  also  because  it  is  the  only  recent  practical 
work  which  M.  Ricord  has  published,  no  edition  of  his  Traite  des  Maladies  Veniriennes  having 
appeared  for  the  last  fifteen  years." 


Every  one  will  recognize  the  attractiveness  and 
value  which  this  work  derives  from  thus  presemirg 
the  opinions  of  these  two  masters  side  by  side.  But, 
it  must  be  admitted,  what  has  made  the  fortune  of 
the  book,  is  the  fact  that  it  contains  the  "most  com- 
plete embodiment  of  the  veritable  doctrines  of  the 
Hopital  du  Midi,"  which  has  ever  been  made  public. 
The  doctrinal  ideas  of  M.  Ricord.  ideas  which,  if  not 
universally  adopted,  are  iiicoiitestably  dominant,  have 
heretofore  only  been  interpreted  by  more  or  less  fkilful 
secretaries,  sometimes  accredited  and  sometimes  not. 


In  the  notes  to  Hunter,  the  master  substitutes  hira- 
selfforhis  interpreters,  and  gives  his  original  thoughts 
io  the  world,  in  a  summary  form  it  is  true,  but  in  a 
lucid  and  perfectly  intelligible  manner.  In  conclu- 
sion we  can  say  that  this  is  inconlestably  the  best 
treatise  on  syphilis  with  which  we  are  acquainted, 
and,  as  we  do  not  often  employ  the  phrase,  we  may 
be  excused  for  expressing  the  hope  that  it  may  find 
a  place  in  the  library  of  every  physician  — Virginia 
Med.  and  Surg.  Journal. 


BY   THE   SAME   AUTHOR. 

LETTERS  ON  SYPHILIS,  addressed  to  the  Chief  Editor  of  the  Union  Medicals. 

With  an  Introduction,  by  Amedee  Latour.     Translated  by  W.  P.  Lattimore,  M.  D.     In  one  neat 
octavo  volume. 

Blanchard  &  Lea  are  now  the  publishers  of  this  valuable  work. 

From  the  Translator's  Preface. 

To  those  who  have  listened  to  the  able  and  interesting  lectures  of  our  author  at  the  Hopital  du 

Midi,  this  volume  will  need  no  commendation;  while  to  those  who  have  not  had  the  pleasure  to 

which  we  allude,  the  book  will  commend   itself  by  the  truths  it  contains,  told  as  they  are  in  the 

same  inimitable  style  in  which  M.  Ricord  delivers  his  clinical  lectures. 

BY   THE   SAME   AUTHOR. 

A  PRACTICAL  TREATISE  ON  VENEREAL  DISEASES.     With  a  Thera- 

peutical  Summary  and  Special  Formulary.    Translated  by  Sidney  Doane,  M.  D.    Fourth  edition. 
Oue  volume,  octavo,  340  pages. 


26 


BLANCHARD   &    LEA'S    MEDICAL 


RIGBY  (EDWARD),   M.  D., 

Physician  to  the  General  Lying-in  Hospital,  Sec. 

A   SYSTEM   OF   MIDWIFERY.     With   Notes  and   Additional  Illustrations. 

Second  American  Edition.     One  volume  octavo,  422  pages. 


ROYLE  (J.  FORBES),   M.  D. 
MATERIA  MEDICA  AND  THERAPEUTICS ;  including  the  Preparations  of 

the  Pharmacopoeias  of  London,  Edinburgh,  Dublin,  and  of  the  United  States.  With  many  new 
medicines.  Edited  by  Joseph  Carson,  M.  D.,  Professor  of  Materia  Medica  and  Pharmacy  in 
the  University  of  Pennsylvania.  With  ninety-eight  illustrations.  In  one  large  octavo  volume, 
of  about  seven  hundred  pages. 


This  work  is,  indeed,  a  most  valuable  one,  and 
will  fill  up  an  important  vacancy  that  existed  be- 
tween Dr.  Pereira's  most  learned  and  complete 
system  of  Materia  Medica,  and   the  class  of  pro- 


ductions on  the  other  extreme,  which  are  neces- 
sarily imperfect  from  their  small  extent. — British 
and  Foreign  Medical  Review. 


SKEY  (FREDERICK  C),   F.  R,  S.,  &.c. 
OPERATIVE  SURGERY.     In  one  very  handsome  octavo  volume  of  over  650 

pages,  with  about  one  hundred  wood-cuts. 


Its  literary  execution  is  superior  to  most  surgical 
treatises.  It  abounds  in  excellent  moral  hints,  and 
is  replete  with  original  surgical  expedients  and  sug- 
gestions.— Buffalo  Med.  and  Surg.  Journal. 

With  high  talents,  extensive  practice,  and  a  long 
experience,  Mr.  Skey  is  perhaps  competent  to  the 
task  of  writing  a  complete  work  on  operative  sur- 
gery.— Charleston  Med.  Journal. 


We  cannot  withhold  from  this  work  our  high  com- 
mendation. Students  and  practitioners  will  find  it  an 
invaluable  teacher  and  guide  upon  every  topic  con- 
nected with  this  department. — N.  Y.  Medical  Ga- 
zette. 

A  work  of  the  very  highest  importance — a  work 
by  itself. — London  Med.  Gazette. 


SHARPEY  (WILLIAM),    M.D.,    JONES   QUAIN,    M.  D.,  AND 
RICHARD   QUAIN,    F.  R.  S.,  &c. 

HUMAN  ANATOMY.     Revised,  with  Notes  and  Additions,  by  Joseph  Leidt, 

M.  D.     Complete  in  two  large  octavo  volumes,  of  about  thirteen  hundred  pages.     Beautifully 
illustrated  with  over  five  hundred  engravings  on  wood. 


It  is  indeed  a  work  calculated  to  make  an  era  in 
anatomical  study,  by  placing  before  the  student 
every  department  of  his  science,  with  a  view  to 
the  relative  importance  of  each  ;  and  so  skilfully 
have  the  different  parts  been  interwoven,  that  no 
one  who  makes  this  work  the  basis  of  his  studies, 
will  hereafter  have  any  excuse  for  neglecting  or 
undervaluing  any  important  particulars  connected 
with  the  structure  of  the  human  frame;  and 
whether  the  bias  of  his  mind  lead  him  in  a  more 
especial  manner  to  surgery,  physic,  or  physiology, 
he  will  find  here  a  work  at  once  so  comprehensive 
and  practical  as  to  defend  him  from  exclusiveness 
on  the  one  hand,  and  pedantry  on  the  other. — 
Monthly  Journal  and  Retrospect  of  the  Medical 
Sciences. 


We  have  no  hesitation  in  recommending  this  trea- 
tise on  anatomy  as  the  most  complete  on  that  sub- 
ject in  the  Englii?h  language;  and  the  only  one, 
perhaps,  in  any  language,  which  brings  the  state 
of  knowledge  forward  to  the  most  recent  disco- 
veries.— The  Edinburgh  Med.  and  Surg.  Journal. 

Admirably  calculated  to  fulfil  the  object  for  which 
it  is  intended. — Provincial  Medical  Journal. 

The  most  complete  Treatise  on  Anatomy  in  the 
English  language. — Edinburgh  Medical  Journal. 

There  is  no  work  in  the  English  language  to  be 
preferred  to  Dr.  Quain's  Elements  of  Anatomy. — 
London  Journal  of  Medicine. 


SMITH  (HENRY    H.),  M.  D.,  AND   HORNER  (WILLIAM  E.),   M.  D. 
AN  ANATOMICAL  ATLAS,  illustrative  of  the  Structure  of  the  Human  Body. 

In  one  volume,  large  imperial  octavo,  with  about  six  hundred  and  fifty  beautiful  figures. 


These  figures  are  well  selected,  and  present  a 
complete  and  accurate  representation  of  that  won- 
derful fabric,  the  human  body.  The  plan  of  this 
Atlas,  which  renders  it  so  peouliarly  cimvenient 
for  the  student,  and  its  superb  artistical  execution, 
have  been  already  pointed  out.     We  must  congratu- 


late the  student  upon  the  completion  of  this  Atlas, 
as  it  is  the  most  convenient  work  of  the  kind  that 
has  yet  appeared  ;  and  we  must  add,  the  very  beau- 
tiful manner  in  which  it  is  "  got  up"  is  so  creditable 
to  the  country  as  to  be  flattering  to  our  national 
pride. — American  Medical  Journal. 


In 


SARGENT  (F.  W.),  M.  D. 
ON  BAND  AGING  AND  OTHER  POINTS   OF  MINOR  SURGERY 

one  handsome  royal  12mo.  volume  of  nearly  400  pages,  with  128  wood-cuts. 

The  very  best  manual  of  Minor  Surgery  we  have  ]  AVe  have  carefully  examined  this  work,  and  find  it 
seen;aii  American  volume,  with  nearly  four  hundred  well  executed  and  admirably  adapted  to  the  use  of 
pages  of  good  practical  lessons,  illustrated  by  about  '  the  student.  Besides  the  subjects  usually  embraced 
one  hundred  and  thirty  wood-cuts.  In  these  days  in  works  on  Minor  Surgery,  there  is  a  short  chapter 
of  '  trial,  when  a  doctor's  reputation  hangs  upon  on  bathing,  another  on  ana;sthetic  agents,  and 
a  clove  hitch,  or  the  roll  of  a  bandage,  it  would  be  !  appendix  of  formulje.     The  author  has  given  an  e 


well,  perhaps,  to  carry  such  a  volume  as  Mr.  Sar 
gent's  always  in  our  coat-pocket,  or,  at  all  events, 
to  listen  attentively  to  his  instructions  at  home. — 
Buffalo  Med.  Journal. 


cellentwork  on  this  subject, and  his  publishers  have 
illustrated  and  printed  it  in  most  beautiful  style. — 
J'he  Charleston  Medical  Journal. 


STANLEY  (EDWARD). 
A  TREATISE  ON  DISEASES  OF  THE  BONES. 

extra  cloth,  286  pages. 


In  one  volume,  octavo, 


AND    SCIENTIFIC    PUBLICATIONS.  27 

ST»LLE  (ALFRED),   M.  D. 
PRINCIPLES  OF  THERAPEUTICS.     In  one  handsome  volume.  ^Preparing.) 

SIMON   (JOHN),  F.  R.  S. 
GENERAL    PATHOLOGY,    as   conducive  to  the   Establishment  of  Rational 

Principles  for  the  Prevention  and  Cure  of  Disease.  A  Course  of  Lectures  delivered  at  St. 
Thomas's  Hospital  during-  the  summer  Session  of  1850.  In  one  neat  octavo  volume.  (Lately 
Issued.) 


SMITH   (TYLER  W.),   M.  D., 

Lecturer  on  Obstetrics  in  the  Hunterian  School  of  Medicine. 

ON   PARTURITION,   AND   THE   PRINCIPLES   AND   PRACTICE   OF 

OBSTETRICS.     In  one  large  duodecimo  volume,  of  400  pages. 


SIBSON    (FRANCIS),    M.D., 

Phj'sician  to  St.  Mary's  Hospital. 

MEDICAL  ANATOMY.     Illustrating  the  Form,  Structure,  and  Position  of  the 

Internal  Organs  in  Health  and  Disease.     In  large  imperial  quarto,  with  splendid  colored  plates. 
To  match  "Maclise's  Surgical  Anatomy."     [Prepariiig.) 

SOLLY  (SAMUEL),    F.  R.  S. 

THE    HUMAN    BRAIN;    its  Structure,  Physiology,  and  Diseases.     With  a 

Description  of  the  Tj'pical  Forms  of  the  Brain  in  the  Animal  Kingdom.    From  the  Second  and 
much  enlarged  London  edition.     In  one  octavo  volume,  with  120  wood-cuts. 


SCHOEDLER  (FRIEDRICH),   PH.D., 

Professor  of  the  Natural  Sciences  at  Worms,  &c. 

THE   BOOK   OF   NATURE;   an  Elementary  Introduction  to  the  Sciences  of 

Physics,  Astronomy,  Chemistry,  Mineralogy,  Geology,  Botany,  Zoology,  and  Physiology.  First 
American  edition,  with  a  Glossary  and  other  Additions  and  Iraprovemenis ;  from  the  second 
English  edition.  Translated  from  the  sixth  German  edition,  by  Henry  Medlock,  F.  C.  S.,  &c. 
In  one  thick  volume,  small  octavo,  of  about  seven  hundred  pages,  wilh  679  illustrations  on  wood. 
Suitable  for  the  higher  Schools  and  private  students.     [Now  Ready.) 

This  volume,  as  its  title  shows,  covers  nearly  all  I  seen  presents  the  reader  with  so  -wide  a  range  of  ele- 
the  sciences,  and  embodies  a  vast  amount  of  informa-  mentary  knowledge,  with  so  full  illustrations,  at  so 
tion  for  instruction.    No  other  work  that  we  have  |  cheap  a  rate. — Silliman's  Journal,  Nov.  1853. 

TAYLOR  (ALFRED  S.),  M.  D.,  F.  R.  S., 

Lecturer  on  Medical  Jurisprudence  and  Chemistry  in  Guy's  Hospital. 

MEDICAL  JURISPRUDENCE.     Third  American,  from  the  fourth  and  improved 

English  Edition.    With  Notes  and  References  to  American  Decisions,  by  Edward  Hartshorke, 
M.  D.     In  one  large  octavo  volume,  of  about  seven  hundred  pages.     (Just  Issued.) 
AVe  know  of  no  work  on  Medical  Jurisprudence 

which  contains  in  the  same  space  anything  like  the 

same  amount  of  valuable  matter. — N.  Y.  Journal  of 


Medicine. 

The  American  editor  has  appended  several  im- 
portant facts,  the  whole  constituting  by  far  the  best, 
most  reliable,  and  interesting  treatise  on  Medical 
Jurisprudence,  and  one  that  ^ve  cannot  too  strongly 
recommend  to  all  who  desire  to  become  acquainted 
with  the  true  and  correct  exposition  of  this  depart- 
ment of  medical  literature. — Northern  Lancet. 

No  work  upon  the  subject  can  be  put  into  the 
hands  of  students  either  of  law  or  medicine  which 
will  engage  them  more  closely  or  profitably  ;  and 
none  could  be  offered  to  the  busy  practitioner  of 
either  calling,  for  the  purpose  of  casual   or  hasty 

BY   THE    SAME   AUTHOR. 

ON  POISONS,  IN  RELATION  TO  MEDICAL  JURISPRUDENCE  AND 

MEDICINE.    Edited,  with  Notes  and  Additions,  by  R.  E.  Griffith,  M.  D.    In  one  large  octavo 
volume,  of  6SS  pages. 


reference,  that  would  be  more  likely  to  afford  the  aid 
desired.  We  therefore  recommend  it  as  the  best  and 
safest  manual  for  daily  use. — American  Journal  of 
Medical  Sciences. 

We  have  heretofore  had  reason  to  refer  to  it  in 
terms  of  commendation,  and  need  now  only  state 
that,  in  the  edition  before  us,  the  author  has  com- 
pletely revised  the  \vhole  work,  making  many  addi- 
tions and  alterations,  and  brought  it  fully  up  to  the 
present  state  of  knowledge.  The  task  of  the  Ameri- 
can editor  has  been  to  present  all  the  important 
facts  and  cases  that  have  recently  occurred  in  our 
own  country,  bearing  on  the  subjects  treated  of. 
No  better  work  can  be  placed  in  the  hands  of  the 
physician  or  jurist. — i,t.  Leuis  Medical  and  Surgical 
Journal. 


The  most  elaborate  w^ork  on  the  subject  that  ou^ 
literature  possesses. — British  and  Foreign  Medico- 
Chirurgical  Review. 

It  contains  a  vast  body  of  facts,  which  embrace 
all  that  is  important  in  toxicology,  all  that  is 
necessary  to  the  guidance  of  the  medical  jurist,  and 
all  that  can  be  desired  by  the  lawyer.  —  Medico- 
Chirurgical  Review. 


One  of  the  most  practical  and  trustworthy  works 
on  Poisons  in  our  language. — Western  Journal  of 
Medicine. 

It  is,  so  far  as  our  knowledge  extends,  incompa- 
rably the  best  upon  the  subject;  in  the  highest  de- 
gree creditable  to  the  author,  entirely  trustworthy, 
and  indispensable  to  the  student  and  practitioner. — 
N.  Y.  Annalist 


THOMSON  (A.  T.),  M.  D.,  F.  R.  S.,  &c. 
DOMESTIC  MANAGEMENT   OF  THE   SICK  ROOM,  necessary  in  aid  of 
Medical  Treatment  for  the  Cure  of  Diseases.    Edited  by  R.  E.  Griffith,  M.  D.    In  one  large 
royal  12mo.  volume,  with  wood-cuts,  360  pages. 


28 


BLANCHARD    &   LEA'S    MEDICAL 


TOMES   (JOHN), 
A  MANUAL  OF  DENTAL  PKACTICE. 

on  wood.     In  one  handsome  volume.     (Preparing.) 


F.  R.  S. 

Illustrated  by  numerous  engravings 


TODD  (R.  B.),   M,  D.,  AND  BOWMAN  (WILLIAM),   F.  R.  S. 
PHYSIOLOaiCAL    ANATOMY   AND    PHYSIOLOGY  OP  MAN.     With 

numerous  handsome  wood-cuts.    Parts  I,  II,  and  III,  in  one  octavo  volume,  552  pages.     Part  IV 

will  complete  the  work. 

The  distinguishing  peculiarity  of  this  work  is,  that  the  authors  investigate  for  themselves  every 
fact  asserted ;  and  it  is  the  immense  labor  consequent  upon  the  vast  number  of  observations  re- 
quisite to  carry  out  this  plan,  which  has  so  long  delayed  the  appearance  of  its  completion.  The 
first  portion  of  Part  IV,  with  numerous  original  illustrations,  was  published  in  the  Medical  News 
and  Library  for  1853,  and  the  completion  will  be  issued  immediately  on  its  appearance  in  London. 
Those  who  have  subscribed  since  the  appearance  of  the  preceding  portion  of  the  work  can  have 
the  three  parts  by  mail,  on  remittance  of  $2  50  to  the  publishers. 

TRANSACTIONS  OF   THE   AMERICAN    MEDICAL   ASSOCIATION. 
VOLUME  VI,  for  1853,  large  8vo.,  of  870  pages,  with  numerous  colored  plates 

and  wood-cuts. 
Also  to  be  had,  a  few  sets  of  the  Transactions  from  1848  to  1853,  in  six  large  octavo  volumes, 
price  $25.     These  volumes  are  published  by  and  sold  on  account  of  the  Association. 

WATSON    (THOMAS),    M.D.,    fitc. 
LECTURES    ON    THE   PRINCIPLES    AND    PRACTICE   OP   PHYSIC. 

Third  American,  from  the  last  London  edition.  Revised,  with  Additions,  by  D.  Francis  Condie, 
M.  D  ,  author  of  a  "  Treatise  on  the  Diseases  of  Children,"  &c.  In  one  octavo  volume,  of  nearly 
eleven  hundred  large  pages,  strongly  bound  with  raised  bands. 

Confessedly  one  of  the  very  best  works  on  the 
principles  and  practice  of  physic  in  the  English  or 
any  other  language. — Med.  Examiner. 

Asa  text- book  it  has  no  equal ;  as  a  compendium 
of  pathology  and  practice  no  superior. — Neiv  York 
Annalist. 

We  know  of  no  w^ork  bett^  calculated  for  being 
placed  in  the  hands  of  the  student,  and  for  a  text- 
book; on  every  important  point  the  author  seems 
to  have  posted  up  his  knowledge  to  the  day. — 
Amur.  Med.  Journal. 

One  of  the  most  practically  useful  books  that 
ever  was  presented  to  the  student.  —  N.  Y.  Med. 
Journal, 


To  say  that  it  is  the  very  best  work  on  the  sub- 
ject now  extant,  is  but  to  echo  the  sentiment  of  the 
medical  press  throughout  the  country.  — iV.  O. 
Medical  Journal. 

Of  the  text-books  recently  republished  Watson  is 
very  justly  the  principal  favorite. — Holmes's  Rejp. 
to  Nat.  Med.  Assoc. 

By  universal  consent  the  work  ranks  among  the 
very  best  text-books  in  our  language. — Illinois  and 
Indiana  Med.  Journal. 

Regarded  on  all  hands  as  one  of  the  very  best,  if 
not  the  very  best,  systematic  treatise  on  practical 
medicine  extant. — St.  Louis  Med.  Journal. 


WALSHE   (W.    H.),    M.  D., 

Professor  of  the  Principles  and  Practice  of  Medicine  in  University  College,  London. 

DISEASES    OF    THE    HEART,    LUNGS,    AND    APPENDAGES;    their 

Symptoms  and  Treatment.     In  one  handsome  volume,  large  royal  12mo.,  512  pages. 
We  consider  this  as  the  ablest  work  in  the  En-  I  the  author  being  the  first  stethoscopist  of  the  day.— 
glish  language,  on  the  subject  of  which  it  treats;  |  Charleston  Medical  Journal. 

WHAT   TO   OBSERVE 
AT    THE    BEDSIDE    AND    AFTER   DEATH,   IN    MEDICAL    CASES. 

Published  under  the  authority  of  the  London  Society  for  Medical  Observation.     In  one  very 

handsome  volume,  royal  12mo  ,  extra  cloth      [Just  Issued.) 

We  hail  the  appearance  of  this  book  as  the  grand    given   to  the  world,   through  a  small    but   useful 

desideratum. Charleston  Medical  Journal.  medical  organization,  a  cheap  but  invaluable  book. 

We  do  advise  every  reader  of  this  notice  to  buy  it 

This   is   truly  a  very  capital  book.     The  whole    j^^j  ^gg  jj      Unless  he  is  so  vain  as  to  imagine  him- 
medical  world  will  reap  advantages  from  its  publi-    self  superior  to  the  ordinary  human  capacity,  he  will 
cation.    The  medical  journals  will   soon  show  its    ;„   gj^.    months  see  its  inestimable  advantages.— 
influence  on  the  character  of  the  •'  Reports  of  Cases'      stethoscope. 
which  they  publish.    Drs.  Ballard  and  Walshe  have 


WILDE   (W.    R.), 

Surgeon  to  St.  Mark's  Ophthalmic  and  Aural  Hospital,  Dublin^ 

AURAL  SURGERY,  AND  THE  NATURE  AND  TREATMENT  OF  DIS- 

EASES  OF  THE  EAR.  In  one  handsome  octavo  volume,  with  illustrations.  (Now  Ready.) 
So  little  is  generally  known  in  this  country  concerning  tlie  causes,  symptoms,  and  treatment  of 
aural  affections,  that  a  practical  and  scientific  work  on  that  subject,  from  a  practitioner  of  Mr. 
Wilde's  great  experience,  cannot  fail  to  be  productive  of  much  benefit,  by  attracting  attention 
to  this  obscure  class  of  diseases,  which  too  frequently  escape  attention  until  past'  relief.  Tne  im- 
mense number  of  cases  which  have  come  under  Mr.  Wilde's  observation  for  many  years,  have 
afforded  him  opportunities  rarely  enjoyed  for  investigating  this  branch  of  medical  science,  and  his 
work  may  therefore  be  regarded  as  of  the  highest  authority. 

laws,  and  amenable  to  the  same  general  meihofis  of 
treatment  as  other  morbid  processes,  rhe  work  is 
not  written  to  supply  the  cravings  of  popular  patro- 


This  work  cerlainly  , contains  more  information  on 
the  subject  to  which  it  is  devoted  than  any  other 
wilh  which  we  are  acquainted.  We  feel  grateful  to 
the  author  for  his  manful  effort  to  rescue  this  depart- 
ment of  surgery  from  the  hands  of  the  empirics  who 
nearly  monopolize  it.  We  think  he  has  successfully 
shown  that  aural  diseases  are  not  beyond  the  re- 
sources of  art;  that  Ihey  are  governed  by  the  same 


nage,  but  it  is  wholly  addressed  to  the  profession, 
and  bears  onevery  page  the  impress  of  the  re  tied  ions 
of  a  sagacious  and  practical  surgeon. —  Va.  Sur^.  and 
Med.  Journal. 


AND    SCIENTIFIC    PUBLICATIONS. 


29 


WILSON    (ERASMUS),   M.D.,    F.  R.  S., 

Lecturer  on  Anatomy,  London. 

A  SYSTEM  OF  HUMAN  ANATOMY,  General  and  Special.     Fourth  Araeri- 

can,  from  the  last  English  edition.  Edited  by  Paul  B.  Goddard,  A.  M..,  M.  D.  With  two  hun- 
dred and  fifty  illustrations.  Beautifully  printed,  in  one  large  octavo  volume,  of  nearly  six  hun- 
dred pages. 


In  many,  if  not  all  the  Colleges  of  the  Union,  it 
has  become  a  standard  text-book.  This,  of  itself, 
is  sufficiently  expressive  of  its  value.  A  work  very 
desirable  to  the  student;  one,  the  possession  of 
which  will  greatly  facilitate  his  progress  in  the 
study  of  Practical  Anatomy. — New  York  Journal  of 
Medicine. 

Its  author  ranks  with  the  highest  on  Anatomy. — 
Southern  Medical  and  Surgical  Journal. 


It  offers  to  the  student  all  the  assistance  that  can 
be  expected  from  such  a  work. — Medical  Examiner. 

The  most  complete  and  convenient  manual  for  the 
student  we  possess. — American  Journal  of  Medical 
Science. 

In  every  respect,  this  work  as  an  anatomical 
guide  for  the  student  and  practitioner,  merits  our 
warmest  and  most  decided  praise. — London  Medical 
Gazette. 


BY   THE   SAME   AUTHOR. 

THE  DISSECTOR  J  or,  Practical  and  Surgical  Anatomy.  Modified  and  Re- 
arranged, by  Paul  Beck  Goddard,  M.  U.  A  new  edition,  with  Revisions  and  Additions.  In 
one  large  and  handsome  volume,  royal  12mo.,  with  one  hundred  and  fifteen  illustrations. 

In  passing  this  w^ork  again  through  the  press,  the  editor  has  made  such  additions  and  improve- 
ments as  the  advance  of  anatomical  knowledge  has  rendered  necessary  to  maintain  the  work  in  the 
high  reputation  which  it  has  acquired  in  the  schools  of  the  United  Slates,  as  a  complete  and  faithful 
guide  to  the  student  of  practical  anatomy.  A  number  of  new  illustrations  have  been  added,  espe- 
cially in  the  portion  relating  to  the  complicated  anatomy  of  Hernia.  In  mechanical  execution  the 
work  will  be  found  superior  to  former  editions. 

BY  THE  SAME   AUTHOR. 

ON    DISEASES    OF   THE    SKIN.     Third  American,  from  the  third  London 

edition.  In  one  neat  octavo  volume,  of  about  five  hundred  pages,  extra  cloth.  [Jitst  Issued.) 
Also,  to  be  had  done  up  with  fifteen  beautiful  steel  plates,  of  which  eight  are  exquisitely  colored; 

represenling  the  Normal  and  Pathological  Anatomy  of  the  Skin,  together  with  accurately  colored 

delineations  of  more  than  sixty  varieties  of  disease,  most  of  them  the  size  of  nature.     The  Plates 

are  also  for  sale  separate,  done  up  in  boards. 

The  increased  size  of  this  edition  is  sufficient  evidence  that  the  author  has  not  been  content 
with  a  mere  republication,  but  has  endeavored  to  maintain  the  high  character  of  his  work  as  the 
standard  text-book  on  this  interesting  and  difficult  class  of  diseases.  He  has  thus  introduced  such 
new  niatter  as  the  experience  of  the  last  three  or  four  years  has  suggested,  and  has  made  such 
alterations  as  the  progress  of  scientific  investigation  has  rendered  expedient.  The  illustrations  have 
also  been  materially  augmented,  the  number  of  plates  being  increased  from  eight  to  sixteen. 

Tlie  "Diseases  of  the  Skin,"   by  Mr.  Erasmus  i      Of  these  plates  it  is  impossible  to  speak  too  highly. 


Wilson,  may  now  be  regarded  as  the  standard  work 
in  that  department  of  medical  literature.  The 
plates  by  which  this  edition  is  accompanied  leave 
nothing  to  be  desired,  so  far  as  excellence  of  delinea- 
tion and  perfect  accuracy  of  illustration  are  con- 
cerned.— Medico-C kirursical  Review. 


The  representations  of  the  various  forms  of  cuta- 
neous disease  are  singularly  accurate,  and  the  color- 
ing exceeds  almost  anything  we  have  met  wilh  in 
point  of  delicacy  and  finish. — British  and  Foreign 
Medical  Review. 


BY   THE   SAME   AUTHOR. 


ON    CONSTITUTIONAL    AND    HEREDITARY    SYPHILIS,   AND    ON 

SYPHILITIC  ERUPTIONS.     In  one  small  octavo  volume,  beautifully  printed,  with  four  exqui- 
site colored  plates,  presenting  more  than  thirty  varieties  of  syphilitic  eruptions. 


Dr.  Wilson's  views  on  the  general  subject  of 
Syphilis  appear  to  us  in  the  main  sound  and  judi- 
cious, and  we  commend  the  book  as  an  excellent 
monograph  on  the  subject.  Dr  Wilson  has  pre- 
sented us  a  verj'  faithful  and  lucid  description  of 
Sypiiilis  and  has  cleared  up  many  obscure  points  in 


connection  with  its  transmissibility,  pathology  and 
sequelae.  His  facts  and  references  will,  we  are  satis- 
fied, be  received  as  decisive,  in  regard  to  many 
questiones  vexatoe.  They  appear  to  us  entitled  to 
notice  at  some  length. — Medical  Examiner . 


BY   THE   SAME    AUTHOR. 


A  TREATISE  ON  THE   MANAGEMENT  OF   THE    SKIN   AND    HAIR 

IN  RELATION  TO  HEALTH.    Second  American,  from  the  fourth  London  edition.    One  neat 
volume,  royal  12mo. 


WHITEHEAD  (JAMES),    F.  R.  C.  S.,    &c. 

THE  CAUSES  AND  TREATMENT  OF  ABORTION   AND   STERILITY; 

being  the  Result  of  an  Extended  Practical  Inquiry  into  the  Physiological  and  Morbid  Conditions 
of  the  Uterus.     Second  American  Edition.     In  one  volume,  octavo,  368  pages.     (Now  Ready.) 
The  simple  title  of  this  work  gives  a  very  imper 


feet  idea  of  its  contents.  The  subject  of  sterility 
occupies  a  mere  fraction  of  space,  and  upwards  of 
one-half  of  the  whole  volume  is  taken  up  with  an 
elaborate  account  of  mensiruati<in  as  a  physiological 
process,  and  of  the  disorders  which  its  deviations 
from  health  are  apt  to  produce. — Medical  Chirurg. 
Revieiv. 
Such  are  the  advances  made  from  year  to  year  in 


this  department  of  our  profession,  that  the  practi- 
tioner who  does  not  consult  the  recent  works  on  the 
complaints  of  females,  will  soon  find  himself  in  the 
rear  of  liis  more  studious  brethr<'n.  This  is  one  of 
the  works  which  must  be  studied  by  those  who 
would  know  what  the  present  state  of  our  knowledge 
is  respecting  the  causes  and  treatment  of  abortion 
and  sterility. — The  Western  Journal  of  Medicine  and 
Surgery. 


30  BLANCHARD    &    LEA'S    MEDICAL 

WEST   (CHARLES),    M.  D., 

Physician  to  the  Hospital  for  Sick  Children,  &c. 

LECTURES   ON   THE   DISEASES   OF  INFANCY  AND  CHILDHOOD. 

Second  American,  from  the  second  and  enlarged  London  edition.  (Now  Ready.)  In  one  volume, 

octavo,  of  nearly  five  hundred  pages. 

From  the  Preface  to  the  Second  Edition. 
In  the  preparation  of  the  second  edition  of  these  Lectures,  the  whole  work  has  been  carefully 
revised.  A  few  formulse  have  been  introduced  and  a  minute  alphabetical  index  has  been  appended 
-while  additions  amounting  altogether  to  fifty  pages,  have  been  made,  wherever  I  felt  that  more 
extended  observation,  or  more  careful  reflection  had  enabled  me  to  supply  some  of  those  deficiencies 
which  I  am  well  aware,  are  still  far  too  numerous.  The  work  now  contains  the  result  of  640 
observations,  and  l'J9  post-mortem  examinations,  chiefly  made  among  16,276  children  who  came 
under  my  notice  during  the  ten  years  of  my  connection  with  the  Children's  Infirmary  in  Lambeth. 

upon  a  subject  which  almost  daily  taxes  to  the  ut- 
most the  skill  of  the  general  practitioner.  He  has 
with  singular  felicity  threaded  his  way  through  all 
the  tortuous  labyrinths  of  the  difficult  subject  he  has 
undertaken  to  elucidate,  and  nas  in  many  of  the 
darkest  corners  left  a  light,  for  the  benefit  of  suc- 
ceeding travellers,  which  will  never  be  extinguished. 
Not  the  least  captivating  feature  in  tliis  admirable 


We  take  leave  of  Dr.  West  with  great  respect  for 
his  attainments,  a  due  .-ippreciation  of  his  acute 
powers  of  observation,  and  a  deep  sense  of  obliga- 
tion for  this  valuable  contribution  to  our  profes- 
sional literature.  His  book  is  undoubtedly  in  many 
respects  the  best  we  possess  on  diseases  of  children. 
The  extracts  we  have  given  will,  we  hope,  satisfy 
our  readers  of  its  value;  and  yet  in  all  candor  we 
must  say  that  they  are  even  inferior  to  some  other 
parts,  the  length  of  which  prohibited  our  entering 
upon  them.  That  the  book  will  shortly  be  in  the 
hands  of  most  of  our  readers  we  do  not  doubt,  and  it 
will  give  us  much  pleasure  if  our  strong  recommend- 
ation of  it  may  contribute  towards  the  result. — The 
Dublin  Quarterly  Journal  of  Medical  Science. 

Dr.  West  has  placed  the  profession  under  deep  ob- 
ligation by  this  able,  thorough,  and  finished  work 


performance  is  its  easy,  conversational  style,  which' 
acquires  force  from  its  very  simplicity,  and  leaves 
an  impression  upon  the  memory,  of  the  truths  it 
conveys,  as  clear  and  refreshing  as  its  own  purity. 
The  author's  position  secured  him  extraordinary  fa- 
cilities for  the  investigation  of  children's  diseases, 
and  his  powers  of  observation  and  discrimination 
have  enabled  him  to  make  the  most  of  these  great 
advantages. — Nashville  Medical  Journal . 


WILLIAMS   (C.   J.   B.),    M.  D.,    F.  R.  S., 

Professor  of  Clinical  Medicine  in  University  College,  London,  &c. 

PRINCIPLES   OF  MEDICINE;   comprising  General  Pathology  and  Therapeu- 

tics,  and  a  brief  general  view  of  Etiology,  Nosology,  Semeiology,  Diagnosis,  Prognosis,  and 
Hygienics.  Edited,  with  Additions,  by  Meredith  Clymer,  M.  D.  Fourth  American,  from  the 
last  and  enlarged  London  edition.     In  one  octavo  volume,  of  476  pages.     {Now  Ready.) 

This  new  edition  has  been  materially  enlarged  and  brought  up  by  the  editor. 

It  possesses  the  strongest  claims  to  the  attention  of  the  medical  student  and  practitioner,  from 
the  admirable  manner  in  which  the  various  inquiries  in  the  diflerent  branches  of  pathology  are 
investigated,  combined,  and  generalized  by  an  experienced  practical  physician,  and  directly  applied 
to  the  investigation  and  treatment  of  disease. — Editor's  Preface. 

The  best  exposition  in  our  language,  or,  we  be-  I  Few  books  have  proved  more  useful,  or  met  with 
lieve,  in  any  language,  of  rational  medicine,  in  its  |  a  more  ready  sale  than  this,  and  no  practitioner 
present  improved  and  rapidly  improving  state. —  I  should  regard  his  library  as  complete  without  it. 
British  and  Foreign  Medico-Chirurg.  Review.  |  — Ohio  Med.  and  Surg.  Journal. 

BY   THE   SAME   AUTHOR. 

A  PRACTICAL  TREATISE  ON  DISEASES  OF  THE  RESPIRATORY 

ORGANS ;  including  Diseases  of  the  Larynx,  Trachea,  Lungs,  and  Pleurae.  With  numerous 
Additions  and  Notes,  by  M.  Clymer,  M.  D.     With|Wood-cuts.    In  one  octavo  volume,  pp.  508. 


YOUATT   (WILLIAM),  V.S. 

THE    HORSE.     A  new  edition,  with  numerous  illustrations;   together  with  a 

general  history  of  the  Horse;  a  Dissertation  on  the  American  Trotting  Horse  ;  how  Trained  and 
Jockeyed;  an  Account  of  his  Remarkable  Performances;  and  an  Essay  on  the  Ass  and  the  Mule. 
By  J.  S.  Skinner,  formerly  Assistant  Postmaster-General,  and  Editor  of  the  Turf  Register. 
One  large  octavo  volume. 

BY   THE   SAME  AUTHOR. 

THE    DOa.     Edited  by  E.  J.  Lewis,  M.  D.     With  numerous  and  beautiful 

illustrations.     In  one  very  handsome  volume,  crown  8vo.,  crimson  cloth,  gilt. 


ILLUSTRATED  MEDICAL  CATALOGUE. 

BLANCHARD  &  LEA  are  preparing  a  Catalogue  of  their  Medical,  Surgical,  and  Scien- 
tific Publications,  containing  descriptions  of  the  works,  with  Notices  of  the  Press,  and 
specimens  of  the  Illustrations,  making  a  pamphlet  of  sixty-four  large  octavo  pages.  It  will 
be  prepared  with  great  care,  and  without  regard  to  expense,  forming  one  of  the  most  beau- 
tiful specimens  of  typographical  execution  as  yet  issued  in  this  country.  Copies  will  be 
sent  by  mail,  and  the  postage  paid,  on  application  to  the  Publishers,  by  inclosing  two  three 
cent  postage  stamps. 


AND    SCIENTIFIC    PUBLICATIONS. 


31 


B.  &  L.  subjoin  a  condensed  list  of  their  publications  in  general  and  educational 
literature,  of  which  more  detailed  catalogues  will  be  furnished  on  application. 
HISTORY  AND   BIOGRAPHY. 

BROWNING'S     HISTORY  OF    THE    HUGUE 

NO TS.  1  vol.  8vo. 
CAMPBEt.L'S  (LORD)  LIVES    OF   THE   LORD 

CHA.Nl;ELLORS  of  England,  from  the  earl- 
iest   rimes  to  the  Reign  of  George  IV.    In  seven 

handsome  crown  octavo  volumes,  extra  clolb  or 

half  morocco. 
CAVIPBELL-S  (LORD)    LIVES  OF  THE   CHIEF 

JUSTICES  OF  ENGLAND,  from    the  Norman 

Conquest.    In  two  handsome  crown  octavo  vols., 

to  maich  the  "  Chancellors." 
DIXON'S    LIFE  OF  WILLIAM  PENN.    A  new 

work.    1  vol.  royal  lymo  ,  exira  cloth. 
GRAHAME'S   COLONIAL    HISTORY    OF    THE 

UNITED  STATES.    2  vols.  Svo.    A  new  edition. 
GUrZOT'S   LIFE   OF  CROMWELL.    Two  large 

vols.,  royal  r2mo.     (Now  readv  ) 
HERVEY'S    MEMOIRS  OF  GEORGE  II.    2  vols. 

royal  I2mo.,  extra  cloth. 
HUGHES'S   OUTLINES   OF   SCRIPTURE  GEO- 

GRAl^HY  AND  HISTORY,  I  vol.,  royal  12mo., 

with  colored  maps.     (.Jnsl  issued.) 
INGERSOLL'S  HISTORY  OF  THE  LATE  WAR. 

2  vols  Svo. 
KENNEDY'S   LIFE   OF    WILLIAM    WIRT.    2d 

edition,  2  vols,  royal  12mo.,  exira  cloth,  with  Por- 
trait. 
Same  work,  library  edition.  2  vols.  Svo. 
KAVANAGH  S  WOMAN  IN   FRANCE  IN  THE 

EIGHTEENTH    CENTURY.    1  vol.  royall2mo., 

extra  cloth 
LOUIS  BLANC'S  FRANCE  UNDER  LOUIS  PHI 

LIPPE,  1830-1840.   2  vols,  crown  8vo.,  extra  cloth. 


LOUIS  BLANC'S  FRENCH  REVOLUTION.  1  vsl. 

crown  Svo  .  extra  eloUi. 
MARSH  (MRS.)  ROMANTIC  HISTORY  OF  THE 

HUGUENOTS.    2  vols,  royal  12mo.,  extra  cloth. 
NIEtJUHR  S  ANCIEN  T  HISTORY.  By  Leonhard 

ScHMiTZ.    in  three  handsome  cro^n  octavo  vols., 

(Lately  Issued.) 
PARDOE'S  FRANCIS  THE  FIRST.    2  vols,  royal 

12mo..  extra  cloih. 
PALGRAVES   NORMANDY  AND    ENGLAND. 

In  three  vols  crown  Svo. .  (Preparing.) 
RUSH'S  COURT  OF  LONDON.    1  vol.  Svo. 
RANKE'S  HISTORY'  OF    1  HE   REFOR.MATION 

IN  GERMANY.    To  he  complete  iji  1  vol.  Svo. 
RANKES  HISTORY  OF  THE  OTTOMAN    AND 

SPANISH  EMPIRES.    Svo.    Price  50  cents. 
RUSSEL'S   LIFE  OF   CHARLES    JAMES   FOX. 

2  vols.,  handsome  royal  12mo.     (Now  ready.) 
Same  Work,  Second  Series.     (Preparing) 
STRICKLAND'S    LIVES  OF  THE  QUEENS  OF 

ENGLAND,  from  the   Norman   Conquest.    Com- 
plete in  6  handsome  crown  Svo,  volumes,  various 

styles  of  binding. 
STRICKLAND'S    LIVES  OP  THE  QUEENS  OF 

HENRY  VIII.    In  one  handsome  crown  Svo.  vol., 

extra  cloth,  various  styles. 
STRICKLAND'S  LIFE  OF  QUEEN  ELIZABETH. 

In  one  hand.^ome  crown  Svo.  volume,  extra  cloth, 

various  styles. 
STEINMEI'ZS    HISTORY  OF    THE    JESUITS. 

2  vols,  crown  8vo.,  extra  cloth. 


MISCELLANEOUS. 


ACTON  (MRS.)  MODERN  COOKERY'.    Edited  by 

Mrs.  S  J  Hai^e.    1  hand.some  volume,  royal  12mo., 

extra  cloth,  with  illusirations. 
ADDI.SON  ON  CONTRACTS,  and  on    Parties   to 

Actions,  ex  contractu.    1  large  octavo  volume,  law 

sheep. 
BUFFUM'S    SIX    MONTHS     IN     THE     GOLD 

MINES,    1  vol.  royal  12mo.,  extra  cloth  or  paper, 

50  cents. 
BAIRD'S  WEST  INDIES  AND  NORTH  AMERI- 
CA.   1  vol.  royal  12mo..  extra  cloth. 
CLA TER  ON  THE  DISEASES  OF  HORSES.  By 

Skinner.    1  vol  l2mo. 
CLATER'S  CATTLE  AND  SHEEP  DOCTOR.    1 

vol.  12mo.,  cuts. 
DON  QUIXOTE.    With  numerous  illustrations  by 

Johauiiot.     2  vols.  Svo.  cloth,  or  half  morocco. 
ENCYCLOPAEDIA   OF    GEOGRAPHY.    In  three 

octavo  vols.,  many  cuts  and  maps,  various  bindings. 
ENCYCLOP.<EDIA  AMERICANA.     14  vols.  Svo., 

various  bindings. 
Vol  14.  hrinaring  the  work  up  to  1846,  sold  separate. 
EXPLORING   EXPEDITION,  NARRATIVE  OF 

Jn  six  vols.,  imperial  quarto,  wilh  several  hundred 

plates,  maps.' and  woodcuts 
EVANSS  SUGAR-PLANTERS  MANUAL.  1  vol. 

Svo  .  extra  cloth,  plates. 
ERMAN'S  TRAVELS  IN  SIBERIA    2  vols,  royal 

12(110.,  extra  cloth. 
FIELDING'S  SELECT  WORKS.    In  one  vol.  Svo. 

cloth,  or  4  parts,  paper. 
FLETCHERS  NOTES  FROM  NINEVEH.    1  vol. 

roval  12mo..  extra  cloth. 
HaVVKER    on   shooting.    Edited  by  Porter. 

With  plates  and  cuts.    1  vol.  Svo.,  beautiful  extra 

cloth,  new  edition.  (Just  Issued.) 
HOLTHOUSES    law  dictionary.    By  Pen- 

I5JGTON     1  vol.  large  12mo..  law  sheep. 
JOHNSON'S    dictionary    OF    GARDENING 

By  Landeeth.    1  vol.  large  royal  12mo.,  630  pages, 

many  cuts. 
LANGUAGE  OF  FLOWERS.    8lh  edition.    1  vol. 

ISrao  .  colored  plates,  crimson  cloth,  gilt 
LEWIS'S  HINTS  TO  SPORTSMEN.    1  vol.  royal 

12mo.,  extra  cloih,  illustrated. 


LYNCH'S    NARRATIVE  OF  THE  U.  S.  EXPE- 
DITION  TO    THE    DEAD   SEA   AND    RIVER 

JORDAN.    1  large  octavo  volume,  wilh  numerous 

plates  and  maps. 
Same  work,  condensed  edition,  in  neal  royal  12mo. 
MaCFARLANES    turkey    AND     ITS     DES- 

TIJN  Y.    2  vols,  royal  12mo.,  extra  cloth. 
MACKAY'S    travels    IN    THE     UNITED 

S  TATES.     2  vols,  royal  12mo..  extra  cloih. 
MARTINEAUS    EA»ERN  LIFE.    1  vol.  crown 

Svo  .  extra  cloth. 
MARTINEAU'S   HOUSEHOLD   EDUCATION.    1 

vol.  royal  12mo.,  extra  cloth. 
FACET'S  HUNGARY   AND  TRANSY'LVANIA. 

2  vols,  royal  12mo.,  extra  cloih. 
PULSZKY-'S  HUNGARIAN   LADY.    1  vol.  royal 

12mo  .  extra  cloth. 
PICCIOLA— The  Prisoner  of  Fenestrella.  Illu.-=traled 

edition,  wilh  cuts,  royal  12mo„  beautiful  crimson 

cloth. 
Same  work,  fancy  paper,  price  50  cents. 
READINGS    FOR    THE     YOUNG     FROM    SIR 

WALTER   SCOTT,    2  vols,  royal   ISmo.,  extra 

crimson  cloth,  plates. 
SELECT    WORKS    OF     TOBIAS     SMOLLETT. 

Cloth  or  paper. 
SHAW'S   OUTLINES   OF   ENGLISH    LITERA- 
TURE.   1  larare  vol.  royal  12ino.,  extra  cloth. 
SMALL  BOOKS  ON  GREAT  SUBJECTS.   In  three 

neat  volumes,  royal  ISmo..  extra  cloth. 
SAM  SLICK'S  NEW  WORK— WISE  SAWS  AND 

MODERN    INSTANCES.     1    vol.    12mo.,    (Now 

Readv) 
THO.M  SON'S    DOMESTIC    MANAGEMENT    OF 

THE  SICK  ROOM.    1  vol.  12iiio. 
WHEATON'S  INTERNATIONAL  LAW.     1  vol 
large  Svo  ,  law  sheep,  or  extra  cloth.    3d  edition, 

much  im|)roved. 
YOUATT  ON  THE  HORSE,  &c.    By  Skinner.    1 

vol  Svo.,  many  cuts. 
YOUATT   ON    THE   DOG.     With   plates.    1  vol. 

crown  Svo..  beauiiful  crimson  cloth. 
YOUATT  ON  THE  PIG.    1  vol.  12mo.,  extra  cloih, 

with  cuts. 
Same  work  in  paper,  price  50  cents. 


NATURAL    SCIENCE. 


AMERICAN  ORNITHOLOGY.  By  Prince  Charles 

Bonaparte.   In  four  handsome  folio  volumes,  wilh 

beautiful  colored  plates. 
ARNOTT'S  ELEMENTS  OF  PHY^SICS.  New  Edi- 

ilioii.  By  Isaac  Hays,  M.  D.  Inoneoclavo  volume, 

with  200  illustralions. 


BRODERIP'S  ZOOLOGICAL  RECREATIONS.    1 

vol.  royal  12aio.,  extra  cloth. 
BOWMAN  S    PRACTICAL   CHEMISTRY.    1  voL 

roval  12mo..  extra  cloth  ;  cuts. 
BIRD'S  NATURAL  PHILOSOPHY.    1  vol.  royal 

12mo.,  with  many  cuts. 


32 


BLANCHAK.D  &    LEA'S    SCIENTIFIC  PUBLICATIONS. 


NATURAL  SCIENCE— Continued. 


BEALE  ON  THE  LAWS  OF  HEALTH  IN  RE- 
LA  HON  TO  MIND  AND  BODY.  1  vol.  royal 
12mo  .  extra  cloih. 

BREWSTER  S  TREATISE  ON  OPTICS.  1  vol. 
12mo..  culs. 

CARPENTER'S  GENERAI/  AND  COMPARA- 
TIVE PHYSIOLOGY.  With  numerous  wood- 
culs.     1  vol   large  Svo  ,  new  edition.  (Preparijig.) 

CARPEN  rER  ON  THE  MICROSCOPE.  Hand- 
somely illustrated.    (Preparing.) 

DANA  ON  CORALS.  1  vol.  royal  4to.,  extra  clolh, 
wilh  vv'ood  cuts. 

Alias  to  do.,  large  imperial  folio,  half  morocco,  with 
over  60  mn?nifiet-nl  colored  plate.s. 

DE  LA  BECHE'S  GEOLOGICAL  OBSERVER. 
1  large  vol.  Hvo  over  300  cuts.  (Now  Ready  ) 

FOWiNES'S  RECENT  WORK  ON  CHEMISTRY. 
New  edition.  By  Bridges.  1  vol.  12ino.,  many 
cuts,  sheep  or  extra  cloth. 

GRAHAM'S  ELEMENTS  OF  CHEMISTRY.  Large 
8vo.,  many  cuts,  (fart  I,  lately  issueii,  Pari  II, 
preparing  ) 

GREGORY  ON  ANIMAL  MAGNETISM.  1  vol. 
royal  ]'2mo. 

GRIFFITH'S  CHEMISTRY  OF  THE  FOUR  SEA- 
SONS.   1  vol.  12mo., many  cuts. 

GRIFFITH'S  MEDICAL  BOTANY.  1  vol.  large 
8vo.,  extra  cloth,  nearly  400  cuts. 

HANDBOOKS  OF  NATURAL  PHILOSOPHY 
AND  ASTRONOMY.  By  Dionysius  Labdner. 
3  thick  vols,  royal  I'imo..  wilh  1000  wood  cuts. 

HERSCHEL'S  OUTLINES  OF  ASTRONOMY. 
1  vol.  crown  8vo..  ex.  cl.,  with  plates  and  wood  cuts. 

HUMBOLDT'S  ASPECTS  OF  NATURE.  2d  edi- 
tion.   1  large  vol.  royal  I'irao.,  extra  cloth. 


HALE'S  ETHNOLOGY  AND  PHILOLOGY  OF 
THE  U.  S.  EXPLORING  EXPEDITION.  I  vol. 
royal  4io.,  extra  cloth. 

JOHNSTON'S  PHYSICAL  ATLAS  OF  NATU- 
RAL PHENOMENA.  In  one  large  and  handsome 
imperial  4to.  vol,,  half  bound  in  morocco,  wilh  26 
maps,  beautifully  colored. 

KNAPP'S  TECHNOLOGY,  OR  CHEMISTRY, 
APPLIED  TO  THE  ARTS  AND  TO  MANU- 
FACTURES. Translated  hy  Ronalds.  Edited  by 
Johnson.  Vol  I.,  with  244  large  wood  engravings. 
Vol.  11.,  large  Svo.,  with  250  wood  engravings. 

MULLER'S  PHYSICS  AND  METEOROLOGY.  1 
vol.  large  8vo..  2  colored  plates,  and  55U  wood-cuts. 

MILLWRIGHT'S  AND  MILLER'S  GUIDE.  By 
Oliver  Evans.  In  one  vol.  Svo. , sheep,  many  plates. 

MATTEUCCI  ON  PHYSICAL  PHENOMENA  OF 
LIVING  BEINGS.  1  vol.  royal  12mo.,  ex.  cl.,  cuts. 

ORR'S  CIRCLE  OF  THE  SCIENCES,  royal  12mo., 
with  numerous  illustrations,  containing  Animal  and 
Vegetable  Physiology,  by  the  Editor  and  Professor 
Owen.  The  Different  Forms  of  the  Skeleton,  by 
Prof.  Owen.  Physical  Geography  and  Geology,  by 
Prof.  Ansted.  Natural  Philosophy,  by  Rev.  W. 
Mitchell.  &c.  &c. 

SOMERVILLES  PHYSICAL  GEOGRAPHY. 
New  edition.    1  large  vol.  royal  12mo..  extra  cloth. 

SCHOEDLER  AND  MEDLOCK'S  BOOK  OF  NA- 
TURE. With  Additions  and  Improvernenis  In 
one  thick  volume,  crown  8vo.,  with  over  679  illus- 
trations. 

WEISBACH'S  PRINCIPLES  OF  THE  MECHA- 
NICS OF  MACHINERY  AND  ENGINEERING. 
2  large  octavo  volumes,  extra  cloth,  900  beautiful 
wood  engravings. 


EDUCATIONAL  WORKS. 


ARNOTT'S  ELEMENTS  OF  PHYSICS.  New  edi- 
tion.   Complete  in  1  vol.  8vo  ,  many  illustrations. 

BOLMAR'S  FRENCH  SERIES.  consLstiug  of: - 
LEVIZAC'S  .ERENCH  GRAMMAR,  1  volume, 

12mo..  sheep. 
PERRIN'S  FABLES,  wilh  Key.  1  vol.  12mo.,  half 

bound. 
COI/LOQUIAL  PHRASES,  1  vol.  18mo.,  hf.  bound. 
AVENTURES  DE  TELEMAQUE,  1  vol.  12mo., 

half  bound. 
KEY  to  do.  do.  do. 

FRENCH  VERBS,  1  vol.*12mo.,  half  bound. 

BAIRD'S  CLASSICAL  MANUAL.  An  Epitome  of 
Ancient  Geography,  Mythology,  Anliquities,  and 
Chronology.    1  vol.  royal  18mo.,  extra  cloth. 

Same  work,  half  bound,  embossed  leather  backs. 

BIRD'S  ELEMENTS  OF  NATURAL  PHILOSO- 
PHY. 1  vol.  royaU2mo.,  sheep,orext.  el.  372  cuts. 

BUTLER'S  ATLAS  OF  ANCIENT  GEOGRAPHY. 
Revised  edition.  1  vol.  Svo.  half  bound,  21  colored 
maps. 

BUTLER'S  GEOGRAP.HIA  CLASSICA.  Revised 
edition;    1  vol.  ]2mo.,  half  bound. 

BREWSTER'S  TREATISE  ON  OPTICS.  With 
additions.  By  Bache.  I  vol.  l2tno.,  half  bound,  cuts. 

BROVVNE'SGREEK  CLASSICAL  LITERATURE. 
1  vol.  crown  Svo  .extra  clolh. 

BROWNE'S  ROMAN  CLASSICAL  LITERA- 
TURE.   1  vol.  crown  Svo.,  ex.  clolh.  (Now  Ready.) 

FOSTERS  HANDBOOK  OF  MODERN  EURO 
PEAN  LITERATURE     1  vol.  royal  12mo., ex.  cl. 

FOWNE^'S  CHEMISTRY  FOR  STUDENTS.  New 
edition.  By  Bridges.  1vol.  royal  12mo.,  many  cuts, 
exira  cloth,  or  sheep. 

GRAHAM'S  ELEMENTS  OF  CHEMISTRY.  2d 
edition,  enlarged  Edited  by  Bridges.  Svo.  many 
cuts.     Part  1.  lately  issued.    Pari  11.,  preparing. 

HERSCHEL'S  OUTLINES  OF  ASTRONOMY.  A 
new  edition.  With  numerous  plates  and  wood- 
cuts.   1  vol.  crown  Svo.,  extra  clolh. 

HUGHES'?  OUTLINES  OF  SCRIPTURE  GEO- 
GRAPHY AND  HISTORY,  1  vol.,  royal  12mo., 
wilh  colored  mips.    (Just  issued.) 

JOHNSTON'S  ATLAS  OF  PHYSICAL  GEOGRA- 
PHY".   1  vol.,  with  26 colored  plates,  hf.  bound.         | 


LARDNER'S  HANDBOOKS  OF  NATURAL  PHI- 
LOSOPHY AND  ASTRONOMY. 
First  Course,   containing  Mechanics,   Hydrosta- 
tics, Hydraulics,  Pneumatics,  Sound,  and  Optics. 
1  very  large  vol.,  royal  12rao.,  sheep,  424  cuts. 
Second  Course,  containing  Heat,  Electricity,  Mag- 
netism, and  Galvanism.  1  vol.  royal  12mo., sheep, 
250  cuts. 
Third  Course,  containing  Astronomy  and  Meteo- 
rology. 1  very  large  vol.,  royal  12mo.,  37  plales 
and  216  wood-cuts.     (Now  ready.) 
MULLERS  PHYSICS  AND  METEOROLOGY.  1 
vol.  Svo..  over  500  beautiful  cuts  and  two  colored 
plales,  extra  clolh. 
NATIONAL  SCHOOL  MANUAL.    4  parts.  12mo. 
ORR'S  PHYSIOLOGY  OF  ANIMAL  AND  VEGE- 
TABLE LIFE.     A  new  and  popular  work.    1vol. 
royal  I2mo.  with  illustrations.     (Just  Ready.) 
SOMERVILLES  PHYSICAL  GEOGRAPHY.    3d 
and  enlarged  edition,  wilh  American  notes.   1  large 
vol.  royal  12mo  .  extra  clolh. 
SHAW'S   OUTLINES    OF    ENGLISH   LITERA- 
TURE.   2d  ed.    With  Sketch  of  American  Litera- 
lure.    By  Tuckebman.    1  vol.  royal  12mo.,  ext  cl. 
SCHOEDLER  AND  MEDLOCK'S  BOOK  OF  NA- 
TURE.    Ertited  and  revised.    1  large  vol.,  crown 
Svo.,  with  679  wood  cuts.    (Now  ready.) 
SCHMITZ  AND  ZUMPT'S  CLASSICAL  SERIES 
FOR  SCHOOLS.    In  neat  royal  18mo.  volumes,  as 
follows  : — 
KALTSCHMIDT'S    LATIN     DICTIONARY. 

Complete, handsome  embossed  leather. 
SCHMITZ'S  ELEMENTARY  LATIN  GRAM- 
MAR AND   EXERCISES. 
SCHMITZ'S  ADVANCED  LATIN  GRAMMAR. 
ADVANCED  LATIN  EXERCISE  BOOK,  wuh 

Selections  for  Reading.     (Now  Ready.) 
CjESAR.  extra  clolh,  with  a  Map. 
SALLUST.  extra  clolh,  wilh  a  Map. 
VIRGIL,  extra  clolh. 
OVID,  extra  cloth. 
HORACE,  extra  cloth. 
LIVY.  exira  cloth,  two  colored  Maps. 
CICERO,  extra  cloth. 

QUINTUS  CURTIUS,  extra  cloth,  with  a  Map. 
CORNELIUS  NEPOS,  now  ready,  extra  cloth. 

OTHER  WORKS  OF  THE  SERIES  PREPARING. 


NOTICE. 

Gentlemen  wlio  receive  this,  and  Postmasters,  are  requested  to  forward  us,  by  mail,  lists 
of  the  physicians  and  principals  of  academies  in  their  counties.  For  all  such  lists,  received 
free  of  postage,  we  will  in  return  send  a  copy  of  "Carpenter  on  the  Use  and  Abuse  of  Alco- 
holic Liquors,"  done  up  in  flexible  cloth,  postage  paid. 

BLANCHARD  &  LEA,  Philadelphia. 


COLUMBIA  UNIVERSITY  LIBRARY 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

F 

JUN  1  9  194 

1 

.m 

9-  3   \>^^^^ 

m%  i    ^^^ 

i 

' 

HPI&v   w 

, 

028(236)  MI  00 

